COLUMBIA  LIBRARIES  OFFSITE 

HEALTH  SCIENCES  STANDARD 


HX641 72880      x  ,o/' 
RC1 26  .St6  Cholera,  its  protean 


RECAP 


By  Dr.  G.  Archie 


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■•aNS^',a}ifc,:!i<piaMiia'r'':  ^  '^\i.  ''^j^  ^g-g^p;' 


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COLUMBIA    UNIVERSITY 
EDWARD  G.  JANEWAY 


MEMORIAL  LIBRARY 


A  TONIC. 


HORSFORD'S  ACID  PHOSPHATE 

Prepared  under  the  direction  of  Prof.  E.  N.  Horsford. 


A  most  excellent  and  agreeable  tonic  and  appetizer.     It 
nourishes  and  invigorates  the  tired  brain  and  body,  imparts 
renewed  energy  and  vitality,  and  enlivens  the  functions. 
Dr.  Ephraim  Bateman,  Cedarville,  N.  J.,  says: 

"  I  have  used  it  for  several  years,  not  only  in  my  practice^ 
but  in  my  own  individual  case,  and  consider  it  under  all  cir- 
cumstances one  of  the  best  nerve  tonics  that  we  possess.  For 
mental  exhaustion  or  overwork  it  gives  renewed  strength  and 
vigor  to  the  entire  system." 


Descriptive  pamphlet  free. 

RUMPORD  CHEMICAL  WORKS, 

PROVIDENCE,  R.  U 


Beware  of  Substitutes  and  Imitations. 

CAUTION:— Be  sure  the,  word  "  MIorsford's  "  is  printed  on  the  lut^el. 
All  others  are  spurious.     Never  sold  in  bulk. 


CHOLERA, 

ITS    PROTEAN    ASPECTS    AND     ITS 
MANAGEMENT. 


DR..  G.  ARCHIE  STOCKWELL,  F.Z.S. 

(^Member  New  Sydenham  Society,  Londoji.) 


In  Two  Volumes — VOL.   I. 


^^  Respice,  aspice,  prospice.' 


1893. 
GEORGE    S.  DAVIS, 

DKTROIT,    MrCH. 


Copyrighted  by 

GEORGE  S.  DA^^S. 

1893. 


DEDICATION. 

To  Or,  Cyrus  M.  Stockwell,  of  Port  Huron,  Michigan — the 
kindest  and  best  of  fathers;  the  most  thorough,  exemplary,  and 
painstaking  of  tutors ;  the  companion  of  youth  and  manhood  ; 
who  early  inculcated  the  necessity  of  close  habits  of  observa- 
tion and  ratiocination,  including  self-segregation  in  all  matters 
scientific — this    volume    is    dedicated  in  deepest    sympathy  and 

love  by 

THE  AUTHOR- 

December  1st,   1892 


PREFACE. 


When  this  volume  was  undertaken,  on  the  spur  of  the 
moment  and  at  the  solicitation  of  the  publisher,  it  was  not 
expected  to  be  more  than  an  exponent  of  personal  views;  but 
in  seeking  collateral  evidence,  I  was  agreeably  surprised  to 
find  myself  by  no  means  singular  in  an  estimate  of  cholera — 
that  many  had  recognized  in  greater  or  less  degree  the  role 
played  by  the  nervous  system,  and  even  admitted  the  possi- 
bility of  profound  toxicity  of  the  cerebro-spinal  centres. 
Hence  was  necessitated  a  work  more  extended  in  scope,  and 
more  generally  particularized  in  outline. 

Again,  I  am  pleased  with  the  opportunity  of  contribut- 
ing my  mite  toward  undoing  the  evil  wrought  by  the  greatest 
medical  heresy  of  any  age — a  heresy  that  seeks  to  elevate  to 
the  acme  of  pathological  knowledge,  a  vain,  visionary, 
theatrical  egoist,  devoid  of  even  the  shadow  of  medical 
training.  The  exponents  of  bacillar  pathology  depend  solely 
upon  hypothetical  assumptions,  ignoring  all  forms  of  evi- 
dence not  adduced  by  themselves.  With  them  the  microscope 
is  no  longer  an  accessory  to  skilled  observation,  but  may 
supersede  the  latter  altogether.  With  profound  contempt 
for  biologico-zoological  laws  and  their  applications,  factitious 
maladies,  artificially  produced,  are  made  to  replace  real 
maladies.  Their  pathology  is  merely  an  experimental  ex- 
perience admitting  of  neither  negations  or  offsets;  their  ther- 
apeutics, a  form  of  still  hunt  with  untried  weapons,  in  an  un- 
known jungle,  after  a  hypothetical  prey.  Indeed,  it  is  a  sad 
travesty  upon  medical  science  when  authors  and  would-be 
teachers  wantonly  assert  Rabies,  Cholera,  Yellow-fever, 
Dengue,  Tetanus,  Endo-carditis,  Pneumonia,  etc.,  are  '' dis- 


eases  zvhose  microhic  origin  is  positively  known'"  when  two  of 
these  are  supported  only  by  manifest  fraud,  in  two  more  the 
evidence  has  never  been  adduced  in  any  form,  and  in  the 
other  three  it  is  of  the  most  flimsy,  superficial  character. — 
The  list  might  be  considerably  increased  as  regards  the  lat- 
ter. The  tendency  is  to  sacrifice  truth  to  temporary  self- 
aggrandizement;  to  assert  individual  preferences  as  estab- 
lished facts,  regardless  of  results,  forgetting  Science  is  a 
stern  mistress  who  permits  neither  preferences  or  personal- 
ities, and  refuses  to  acknowledge  evidence  that  is  not  freed 
from  the  errors  of  coincidence  and  ably  supported  by  neg- 
atives; 

In  conclusion,  I  will  here  make  special  acknowledgment 
of  indebtedness  to  Doctor  Alexander  Harkin  of  Belfast,  Ire- 
land, for  copies  of  his  researches  into  the  aetiology,  pathology 
and  treatment  of  cholera,  which  lead  anything  hitherto  pub- 
lished upon  this  subject;  his  views  are  so  in  accord  with  my 
own,  that  frequently  the  former  have  by  preference  been 
adopted  in  toto,  consequently  the  chief  merit  of  this  work 
will  remain  with  him — not  me. 

I  have  also  availed  myself  freely  of  the  labors  of  Felix 
von  Niemeyer.  Thomas  Hawkes  Tanner,  and  Hermann 
Lebert,  whose  cholera  essays  are  models  of  diction  and  pro- 
found epitomes  of  information  concisely  expressed;  also  of 
the  researches  of  Surgeon-Majors  T.  R.  Lewis,  D.  D.  Cun- 
ningham, J.  M.  Cunningham,  E.  A.  Parkes,  and  J,  C.  Hall; 
Sir  Wm.  Aitken,  Sir  Thos.  Watson,  Geo,  Johnson,  M.  J.  von 
Pettenkofer,  G.  V.  Black,  A.  M.  Brown,  Geo.  Crookshanks, 
Rudolf  von  Jaksch,  James  Gagney,  et  al. 

I  will  likewise  acknowledge  special  courtesies  at  the 
hands  of  Dr.  Thos.  C.  Minor,  of  Cincinnati,  and  the  Sec- 
retary of  the  Tennessee  State  Board  of  Health,  whereby  was 
obtained  a  large  portion  of  the  material  embodied  in  the 
Appendices. 


VII 

Thus  the  volume  makes  little  pretense  to  originality 
further  than  as  a  condensed  rescript  from  others,  supple- 
mented by  personal  views  as  evolved  by  practical  observa- 
tion and  experience. 

Geo.  Archie  Stockwell. 

650  Congress  Street  E., 
Detroit,  Mich. 


CHAPTER  I. 

HISTORY. 

In  the  ranks  of  the  medical  profession,  no  less 
than  in  lay  circles,  the  subject  of  Cholera*  is  one  of 
supreme  and  absorbing  interest,  especially  now  that, 
in  epidemic  form,  it  is  knocking  vigorously  at  our 
very  gates,  so  to  speak,  and  sedulously  endeavoring 
to  force  an  entrance. 

For  a  number  of  years  Americans  have  solaced 
themselves  with  the  idea  that  modern  science  had 
effectually  barricaded  cholera  from  Europe,  and  con- 
sequently from  the  Western  Hemisphere,  except  in  the 
sporadic  form  that  is  always  more  or  less  prevalent  in 
Mediterranean  ports,  and  occasionally  asserts  itself 
in  the  United  States  as  a  concomitant  of  the  heated 
term.  But,  while  the  general  progress  of  sanitation 
in  the  civilized  world  has  been  considerable,  and  such 
as  in  great  measure  to  remove  the  faulty  conditions 
under  which  the  disease  flourishes,  scientists  are 
rudely  awakened  by  the  fact  the  danger  line  has  by 
no  means  been  eradicated,  that  the  barriers  of  pro- 
tection have  been  silently  and  unexpectedly  forced, 
and  that  if  immunity  of  the  American  continent  is  to 
be  secured  it  is  only  at  the  price  of  "  eternal  vigi- 
lance "  coupled  with  more  perfect  knowledge. 

*From  ;^^oAaS,  "the  bowels,"  and  peoo,  "to  flow" — not, 
as  has  been  imagined,  from  X<^^V<  "bile,"  and  psoa. — S. 

I    KKK 


When  are  recalled  the  fearful  and  weird  tales  of 
various  visitations,  and  the  universal  panic  that  in  each 
instance  has  resulted,  it  is  little  wonder  the  public 
await  breathlessly  each  successive  cholera  bulletin, 
fearing  the  dread  malady  has  broken  bounds  and,  con- 
sequently, may  at  any  moment  manifest  itself  in  the 
very  midst  of  the  most  remote  community. 

Evidently  the  disease  has  prevailed  for  untold 
centuries  in  portions  of  the  Orient,  and  manifested 
itself  as  both  an  endemic  and  epidemic  in  the  Indian 
Peninsulas,  where — until  quite  recently  at  least — it 
has  ever  been  regarded  as  a  filth  disease.  It  is  only 
within  the  last  three-fourths  of  a  century,  however, 
that  it  has  manifested  any  predilection  for  Europeans, 
prior  to  this  period  being  universally  regarded  as  a 
plague  peculiar  exclusively  to  dirty,  badly-housed,  ill- 
fed  "heathen."  In  Siam  and  Burma  cholera  is  always 
present;  in  Hindustan  it  is  wont  to  ravage  certain  dis- 
tricts with  great  regularity,  being  in  the  main  an  ac- 
cessory to  religious  pilgrimages,  shrine-worship,  etc., 
especially  when  any  considerable  number  of  natives 
are  assembled  together.  It  remains  a  regular  visitant 
at  the  annual  festivals  held  at  the  great  Conjeveram 
Pagoda,  forty-five  miles  from  Madras,  whence  the  lat- 
ter city  is  regularly  infected,  and  at  the  great  gather- 
ings of  Allahabad.  It  was  a  constant  attendant  upon 
"  The  Jagannath,"  as  held  at  Puri,  a  town  of  35,000 
inhabitants,  that  was  generally  healthy  in  June  and 
July,  but  invariably  developed  cholera  the  succeeding 


—  3  — 
month  with  the  influx  of  some  150,000  pilgrims,  who 
filled  the  lodging-houses  almost  to  the  point  of  suffoca- 
tion, and  crowded  even  the  streets  and  fields,  literally 
covering  both  with  their  urine  and  excrement  the 
decaying  odors  of  which  terribly  impregnated  the  at- 
mosphere for  miles  about;  here  the  disease  claimed 
its  victims,  not  by  scores  but  by  hundreds,  yet  speed- 
ily ceased  its  ravages  on  the  dispersion  of  the  multi- 
tude and  subsequent  thorough  amalgamation  of  their 
filth  with  the  soil. 

It  was  only  in  the  early  part  of  the  present  cent- 
ury that  the  malady  first  appeared  in  Jessur,  in 
Bengal  (sixty-seven  miles  north-east  of  Calcutta),  as 
an  epidemic,  infectious,  pestilential  disorder,  and  over- 
stepping its  natural  boundaries  began  a  deadly  march 
northward  and  westward  that  did  not  cease  for  seven- 
teen years,  and  is  supposed  to  have  claimed  nearly 
600,000  victims.  Sir  Archibald  Allison  thus  tells  the 
tale  :* 

"After  the  signature  of  the  treaty  of  alliance 
with  Scindia,  November  5th,  181 7,  the  cholera,  then 
for  the  first  time  known  in  British  history,  broke  out 
with  the  utmost  violence  in  Lord  Hastings'  army,  and 
from  the  very  outset  committed  the  most  dreadful 
ravages.  The  year  had  been  one  of  great  scarcity; 
the  food  crops  were  of  inferior  quality;  the  situation 
of  the  British  cantonment  low  and  unhealthy.     Every- 


*"  History  of  Europe,"  vol.  vi.    Edinburgh,  1865. 


—  4  — 

thing  was  thus  prepared  for  the  ravages  of  the  epi- 
demic, which  soon  set  in  with  terrible  severity.  For 
ten  days  the  camp  was  nothing  but  a  hospital;  in 
one  week  764  soldiers  and  8,000  camp-followers 
perished.  At  length  the  troops  were  removed  to 
higher  and  more  airy  cantonments,  and  upon  this  the 
malady  ceased — a  memorable  fact  for  the  instruction 
of  future  times.  As  was  afterwards  experienced,  the 
ravages  of  the  pestilence  were  greatest  among  the 
lower  classes  of  the  people.  Only  148  Europeans 
perished  in  November,  but  about  10,000  natives  fell 
victims  to  the  malady  during  the  same  period.  When 
it  spread  to  Calcutta  it  destroyed  200  a  day  for  a  long 
time,  chiefly  amongst  the  worst-fed  and  most  destitute 
people." 

So  far  as  can  be  gathered,  the  epidemic  that  now 
threatens  this  country,  and  is  already  afflicting  por- 
tions of  Western  Europe,  in  March  or  April  of  the 
present  year  appeared  in  the  northern  portion  of 
hither  India,  near  the  head  waters  of  the  Ganges.  It 
first  manifested  itself  in  a  region  a  hundred  miles  or 
so  from  Mirut,  and  two  hundred  and  fifty  north  from 
Lucknow,  among  the  pilgrims  at  the  great  Hurdwar 
Fair.  Thence  it  moved  northward  by  Lahore  into 
Kashmir,  reaching  Peshawar,  showing  itself  violently 
at  Srinagar  and  in  the  Punjab  in  May,  a  month  later 
ravaging  Askabad  after  traversing  the  whole  breadth 
of  Afghanistan.  Here,  having  reached  the  Trans- 
Caspian  railway,  it  moved  more  rapidly,  securing  two 


points  of  distribution — one  at  Baku  via  the  Trans- 
Caucasian  railway,  whence  it  reached  Tiflis,  Persia,  on 
June  26th;  the  other  at  Astrakhan,  at  the  mouth  of  the 
Volga,  where  it  broke  out  June  30th,  and  was  carried 
by  steamboat  traffic  up  that  river  as  far  as  Tzaritzyn, 
.  Saratov,  Samara,  Kazan,  into  the  Province  of  Kos- 
troma, even  spreading  to  Perm  and  Nijni-Novgorod, 
and  to  Ekaterinburg  in  the  Oural.  Moskva  (Moscow) 
became  infected  August  5th,  St.  Petersburg  twelve 
days  later,  when  the  German  ports  quickly  caught  the 
-epidemic,  which  probably  entered  both  by  crossing 
the  Prussian  frontier  (rail  route)  and  by  sea  (via  the 
Baltic).* 

Since  its  inception  in  the  Northwest  Province  of 
India,  not  only  has  it  traveled  the  course  just  indi- 
cated, but  it  likewise  covered  or  overflowed  many 
thousand  square  miles  of  territory,  disseminating  itself 
in  very  much  the  same  way  as  did  the  terrible  epidemic 
of  sixty  years  agone;  and  all  the  epidemics  that  have 
afflicted  Europe,  both  before  and  since,  appear  to 
have  closely  adhered  to  the  same  line  of  progression, 
showing  that  epidemic  history  tends  to  repeat  itself. f 

This  is  a  matter  worthy  of  more  than  passing  at- 


*  It  is  to  be  remarked  also,  that  Hamburg  has  ever 
appeared  a  dangerous  point  of  distribution  for  Western 
Europe. — .S. 

f  It  is  notable,  both  the  present  epidemic  and  that  of 
1867,  began  at  the  Hurdwar  Fair,  which  is  said  to  attract  as 
high  as  three  millions  of  pilgrims  each  season. — S. 


—  6  — 

tention,  since  the  present  plague,  unless  abruptly- 
stayed  in  its  course,  may  possibly  (though  it  is  not 
probable)  in  its  ravages  duplicate  those  of  1829-34. 
It  may  be  added,  moreover,  that  the  malady  follows 
precisely  the  same  laws  in  Europe  and  America  as  in 
the  Orient;  that  it  adheres  closely  to  trade  routes, 
and  advances  from  the  various  points  where  the  seed 
is  sown  (for  reasons  hereinafter  explained)  with  inter- 
vening intervals  of  uncertain  duration,  in  proportion 
to  the  facilities  of  communication;  that  it  is  in  no 
inconsiderable  degree  dependent  upon,  and  influenced 
by,  seasonal  and  atmospheric  conditions,  dying  out 
when  these  latter  are  modified  or  removed.  Further, 
since  it  is  only  too  plainly  apparent  that  land  quaran- 
tines and  sanitary  cordons,  which  European  nations 
are  ever  ready  to  enforce  against  their  neighbors, 
have  not  been  successful  in  keeping  out  the  epidemic, 
the  utterance  of  Prof.  S.  L.  Pisani,  who  is  one  of  the 
most  practical  as  well  as  sanguine  sanitarians,  pos- 
sesses double  weight:  "Experience  has  taught  that  it 
is  not  in  our  power  to  prevent  the  importation  of  the 
germs  of  cholera,  and  that  on  good  sanitation  we 
should  exclusively  rely;  let  the  soil  be  sterilized;  let 
the  seed  fall  on  barren  rock,  and  it  will  not  germinate 
whether  the  season  be  favorable  or  not." 

According  to  Dr.  Wm.  Farr,f  and  also  Dr.  J.  C. 
Morton,  cholera  has  probably  always  existed  in  spor- 

•j-  "  Report  on  the  Mortality  of  Cholera  in  1848-49."  Lon- 
don, 1852. 


adic  form  in  England  and  Europe,  and  this  fact  only 
serves  to  add  fuel  to  the  flame  of  an  epidemic.  They 
cite  several  "  plagues"  as  presenting  choleraic  charac- 
teristics, among  others  that  so  carefully  described  by 
Sydenham  in  the  seventeenth  century,  but  which, 
however,  appears  to  have  more  nearly  approached  a 
dysenteric  flux.  * 


*See  Appendix  A. 


CHAPTER  11. 

EPIDEMIOLOGY. 

The  medical  world  is  to-day  as  ignorant  of  the 
primary  derivation  of  cholera  as  ever,  though  numer- 
ous and  varied  hypotheses  are  not  wanting.  It  is 
possible,  perhaps  even  probable,  that  in  its  natural 
home,  in  the  great  river  deltas  of  lower  Bengal  and 
of  Siam  and  Burma,  where  it  is  endemic,  it  results 
from  miasm;  but  whether  or  not  this  miasm  is  devel- 
oped on  diseased  rice,  as  has  been  suggested,  it  must 
be  admitted  the  disease,  in  its  more  malignant  form 
at  least,  was  originally  exotic  to  Europe  and  America, 
and  even  now  depends  for  its  vigor,  more  or  less, 
upon  the  constitutional  dyscrasige  of  individuals,  and 
for  its  persistence  upon  certain  telluric,  meteoro- 
logic,  atmospheric,  and  concomitant  unsanitary  con- 
ditions. 

It  is  especially  noticeable,  all  others  things  being 
equal,  that  epidemic  cholera  flourishes  best — that  is, 
attacks  more  people,  is  more  fatal,  and  more  rapidly 
extends  itself  geographically — under  two  special  con- 
ditions: 

First. — During  a  high  temperature  of  air  and 
earth : 

Second. — At  periods  when  the  variations  of 
ground  water  and  temperature  are  capricious,  abrupt, 
without  warning. 


—  9  — 

Thus,  in  October,  and  early  November  perhaps, 
in  the  northern  temperate  zone,  when  the  majority  of 
people  are  day  by  day  vacillating  between  light  cloth- 
ing and  heavy  wraps — when  colds,  influenza,  and 
malaria,  are  especially  rampant,  and  other  diseases 
prevalent  that  are  the  outcome  of  carelessness,  de- 
ficient body-temperature,  or  overheating, — the  ravages 
of  cholera  are  apt  to  be  greater  than  in  December, 
when  heavy  clothing  and  heated  houses  are  the  rule. 
So  too,  the  epidemic  is  more  active  in  July  and 
August,  when  the  days  are  insufferably  hot  and  the 
nights  cool  with  heavy  dews,  than  in  either  September 
or  June.  Again,  the  history  of  the  disease  in  Asia, 
Europe,  and  America,  evidences  that  in  high  and  dry 
situations,  in  cold  climates,  wherever  there  is  a  mod- 
erately uniform  or  gradually  progressing  or  regressing 
temperature  during  the  twenty-four  hours,  its  spread 
in  the  main  is  limited  and  slow;  while  in  low-lying 
moist  places,  especially  in  hot  climates  that  present 
extremes  of  humidity  between  meridian  and  the  suc- 
ceeding sunrise,  its  ravages  are  apt  to  be  most  severe 
and  oftentimes  quite  uncontrollable.  In  both  farther 
and  hither  India,  it  has  been  observed  the  pestilence 
suddenly  springs  into  activity  with  the  arrival  of  the 
southeast  monsoon  which,  charged  with  humidity 
from  the  Pacific  Ocean,  frequently  causes  a  fall  in 
temperature  of  as  much  as  fifteen  to  thirty  degrees 
within  almost  as  many  minutes. 

Further  evidence  of  the  part  played  by  telluric. 


meteorologic — and  likewise  astronomic — conditions,  is 
had  in  the  fact  that  when  cholera  is  endemic  to  vol- 
canic regions,  it  becomes  more  active  and  virulent  in 
those  seasons  when  there  is  an  accession  of  volcanic 
action,  or  when  such  is  pending;  the  disease  was  ex- 
ceedingly active  and  pernicious  throughout  the  Indian 
Archipelago  and  the  Malay  Peninsula  after  the  Sum- 
bwa  eruption,  and  all  enteric  maladies  of  choleraic 
nature  were  then  greatly  increased  and  obtained  new 
impetus.  In  Middle  and  Eastern  Europe,  when  the 
epidemic  of  1830-34  was  at  its  height,  it  was  ob- 
served, birds,  quadrupeds,  fish,  and  even  insects,  suf- 
fered, both  prior  and  during  the  epidemic,  from  un- 
known maladies  that  caused  their  death  in  great 
numbers;  the  same  was  true  in  India;  also  of  the 
United  States,  in  varying  degree  according  to  topo- 
graphical features  and  surroundings.  Dr.  O.  D. 
Norton,  of  Cincinnati,  recalls  that  in  that  city,  in 
1849,  when  cholera  was  especially  virulent,  birds  died 
in  their  nests,  and  even  the  house  flies  and  musqui- 
toes  were  exterminated.  The  same  phenomena  have 
accrued  to  certain  portions  of  Europe  the  present 
year.  Again,  each  successive  cholera  epidemic  that 
swept  the  civilized  world,  has  been  preceeded  or 
accompanied  by  profound  disturbances  within  the 
solar  system,  this  year  it  being  the  occultation  of 
Mars;  also  by  evidences  of  famine:  Finally,  the 
great  epidemics  of  influenza  of  this  century,  though 
their   appearance   may  be    coincidences   merely,  are 


—   II   — 


certainly  suggestive  in  that  in  each  instance,  viz.,  in 
1805-34;  1847-49;   1851-53;  1864-65;  1890-91,  they 
preceded  an  epidemic  of  cholera.     Sir  Thomas  Wat- 
son especially  notes  this  fact;  and  John  McLean  for 
twenty-five  years  a  Hudson  Bay  factor,  observed  the 
same  in  the  peninsula  of  Labrador,  where  the  natives 
(Nascopies  and  Innuits)  were  first  decimated  by  influ- 
enza, then  ravaged  with  an  epidemic  of  choleraic  char- 
acter; further,  it  is  somewhat  striking  that  both  mala- 
dies, to  use  the  words  of  Watson,  "  issuing  from  their 
cradle  in  the  East,  traversed  the  northern  countries  of 
Europe  till,  arriving  at  its  western  boundary,  they 
divided  into  great  two  branches;  the  one  proceeding 
onward  across  the  Atlantic,  the  other  turning  in  a  retro- 
grade direction  toward  the  south  and  east."    Between 
the  two  epidemics  moreover,  there  is  marked  similitude 
or  analogy,  the  main  differences  being  that,  whereas 
one  spared  but  very  few  and  was  seldom  fatal,  the 
other  smote  yery  few,  but  with  so  deadly  a  stroke  that 
the  death  rate  was  exceptionally  high.     Both  are  in  a 
sense  general  epidemics,  affecting  the  whole  system 
but  especially  manifest  in  the  nervous  portion;  in  both 
the  most  prominent  symptoms  are  referable,  in  the 
majority    of    cases,  to    the    mucous   membranes— to 
those  of  the  air  passages  in  influenza,  to  those  of  the 
alimentary  canal  in  cholera. 

Surgeon-Majors  T.  R.  Lewis  and  D.  D.  Cunning- 
ham, who  investigated  cholera  in  India  for  eleven 
years  consecutively  (1869  to  1880)  under  orders  from 


Her  Majesty's  Secretaries  of  State  for  War  and  India, 
remark,*  that  in  manifesting  a  marked  partiality  for  a 
soil  of  the  character  of  the  Brahmaputric  and  Gangetic 
alluvium,  "  cholera  is  by  no  means  singular,  for  it  is  a 
well  established  fact  that  malarious  fevers  and  kindred 
disorders  flourish  with  most  vigor  about  the  deltas  of 
large  rivers  all  over  the  world,"  .  .  .  but  they 
would  not,  however,  "  be  understood  to  imply  that  the 
causes  productive  of  malarial  fevers  and  cholera  are 
identical,  or  that  the  localities  providing  the  condi- 
tions necessary  for  the  development  of  the  one  must 
necessarily  provide  those  for  the  other  also." 

Speaking  of  the  Andamans,  where  this  malady 
has  never  flourished  and  malaria  is  always  rampant, 
Dr.  Lewis  says:  "  Notwithstanding  the  Islands  are 
within  three  days  of  India,  and  twenty-four  to  thirty- 
six  hours  of  Burma,  and  that  during  the  last  twenty 
years  steamers  have  constantly  passed  between  the 
two  countries  and  the  Settlement,  ...  it  is  only 
on  rare  occasions  that  cases  of  cholera  have  been  reg- 
istered as  occurring." 

Of  these  rare  cases  Dr.  Rean,  principal  medical 
officer  of  the  Settlement,  says  "  the  patients  were 
generally  admitted  from  some  feverish  locality,  or  had 
been  employed  on  works  of  an  unhealthy  character." 

The  importance  of  well  authenticated  cases  of 
this  nature  can  scarcely  be  overrated  in  connection 

*"Physiological  and  Pathological  Researches."    London, 


—  13  — 
with  the  aetiology  of  cholera;  they  strongly  evidence 
the  correctness  of  the  views  promulgated  by  both  Chas. 
Macnamara*  and  Max  von  Pettenkofer,f  and  assimi- 
late, so  to  speak,  the  two.  Questions  of  possible  in- 
fection or  of  water-contamination  by  specific  imported 
material,  can  hardly  be  seriously  entertained  here. 
With  the  restrictions  surrounding  this  isolated  con- 
vict settlement  there  can  be  no  casual  importation 
of  cases,  as  the  recent  history  of  every  person  is  ac- 
curately known.  Similar  seizures,  moreover,  occur 
habitually  in  every  city  of  India,  as  well  as  every 
summer  and  autumn  in  all  the  large  cities  of  Europe, 
and  also  in  America,  but  excite  no  special  comment 
unless  an  epidemic  supervenes,  or  is  already  rampant, 
when  these  otherwise  ignored  cases  are  seized  upon, 
collated,  and  described  as  foci  of  the  pestilence.  It 
is  not  the  custom  then  to  regard  such  cases  as  due  to 
a  localized  generation  of  the  disease,  and  the  fact  the 
comma  bacillus  may  be  detected  is  held  conclusive 
evidence,  ignoring  the  well  established  fact  that  this 
microbe  is  by  no  means  pathognomonic,  but  present 
even  in  conditions  of  health. | 


*  "  A  Treatise  on  Asiatic  Cholera,"  London.  1870. 

f "  Die  Verbreitungsart  der  Cholera  in  Indien,  nebst 
Atlas."  Braunschwig,  1871. 

X  At  the  moment  of  this  writing  it  is  announced  cholera 
has  found  foot-hold  in  the  city  of  New  York,  the  evidence 
resting  solely  upon  the  presence  of  the  comma  bacillus.  That 
this  is,  presumptively,  an  error  is  shown  by  the  press  reports, 


—    14  — 

That  in  the  present  stage  of  knowledge  it  is  im- 
possible to  explain  all  the  phenomena  of  cholera 
distribution  by  telluric  or  meteorologic  conditions, 
may  be  allowed,  yet  neither  can  such  influences  be 
denied.  It  must  be  remembered  the  same  difficulties 
obtain  in  regard  to  malaria  and  kindred  diseases,  and 
that  one  has  as  substantial  claim  to  this  theory  of 
diffusion  as  the  other.  And  that  cholera  in  its  setio- 
logical  relations  does  present  marked  parallelism  to 
other  diseases  that  are  dependent  chiefly  upon  topo- 
graphical surroundings  for  propagation,  is  proved  by 
the  fact  even  malaria  sometimes  breaks  loose  from 
its  endemic  haunts  and  shows  itself  in  places  where 
it  before  was  totally  unknown.  Thus,  says  M.  von 
Hertz*  it  "  sweeps  over  considerable  regions  of 
country  as  an  epidemic,  and  over  vast  sections  of  the 
globe  as  a  pandemic.  ...  It  does  not  seem  probable 
that  currents  of  air  are  capable  of  carrying  the  poison 
generated  to  a  distance  of  any  considerable  number 
of  miles;  I  believe  rather  it  is  in  a  majority  of  cases 
generated  upon  the  spot.  It  is  a  still  more  difficult 
matter  to  account  for  those  isolated  areas  of  malarial 


that  declare  two  patients  were  ill  with  the  malady  eight 
days.  In  exotic  cholera,  fatality  supervenes,  or  convalescence 
begins,  usually,  ere  the  fifth  day  succeeding  seizure  has 
opened.  Presumably  the  cases  were  all  indigenous  in 
character. — S. 

* "  Cyclopoedia  of    Practical    Medicine;"  von  Ziemssen. 
New  York.     1874. 


—  15  — 
poison  that  are  often  confined  to  single  streets,  to  one 
side  of  a  street,  or  even  single  houses."* 

It  is  a  matter  of  common  experience  that  removal 
from  a  locality  m  which  cholera  exists  is  a  remedy 
against  the  spread  of  the  disease,  and  the  East  Indian 
Government  has  for  many  years  acted  on  this  knowl- 
edge, with  regard  to  its  troops  and  convicts,  with 
gratifying  success.  It  is  equally  a  matter  of  experi- 
ence the  disease  is  most  virulent  in  those  years  when, 
owing  to  telluric  and  meteorologic  conditions,  the  food 
crops  are  more  or  less  a  failure  and  famine  threatens; 
and  that,  while  it  manifests  itself  with  unusual  severity 


*That  the  parallel  between  malaria  and  cholera  is  much 
more  close  than  generally  imagined  is,  however,  evidenced 
in  that  both  depend  for  their  phenomena  (as  is  shown  of  chol- 
era in  Chap.  IV,  p.  56,  and  Chap.  VIII,  pp.  105,  no)  upon 
disturbances  of  the  vaso-motor  system. 

The  contracted  vessels  of  the  skin  and  the  rigors  asso- 
ciated with  the  cold  stage  in  malaria,  are  evidences  of  hyper- 
trophy and  hyperesthesia  of  vaso-motor  nerves;  while 
increased  temperature,  flushed  surface,  full  pulse,  and  the 
dilated  blood  vessels  accompanying  pyrexia,  exhibit  tissue 
paralysis,  both  nervous  and  muscular.  The  splenic  and 
hepatic  engorgements,  and  the  diarrhoeas  and  dysenteries 
that  are  so  frequent  sequels  of  malarial  poisoning,  are 
derived  from  dilated  and  paralyzed  arteries,  and  conse- 
quently excessive  flow  of  blood  to  undilated,  enfeebled  tissue. 
In  cholera,  too,  we  have  paralyzed  blood  vessels;  but  there 
is  also  another  dangerous  factor,  in  a  measure  specific  and 
dependent  upon  the  former,  in  that  the  blood  itself  is  con- 
stantly and  rapidly  being  deprived  of  its  serum. — S. 


—   i6  — 

in  certain  localities,  in  others  closely  contiguous  its 
ravages  are  comparatively  mild  or  wholly  absent. — 
How  often  has  it  been  observed  in  the  case  of  an 
outbreak  that  shifting  a  ship  a  few  hundred  yards 
from  its  anchorage,  or  crossing  to  the  other  side  of  a 
river,  has  sufficed  to  end  an  epidemic  ! 

An  instance  in  fact  may  be  cited  in  the  visitation 
of  America  in  1853-54,  when  Sarnia,  Ontario,  and  St. 
Clair,  Michigan,  suffered  severely,  while  Port  Huron, 
just  across  the  river  from  the  former  and  twelve  miles 
above  the  latter,  had  but  three  cases,  and  these,  there 
is  every  reason  to  believe,  obtained  the  infection  in 
Canada. 

At  this  period  neither  of  these  towns  was 
provided  with  sewers  or  any  form  of  drain- 
age other  than  afforded  by  natural  topography, 
and  the  fermenting  and  decaying  "  sawdust  pave- 
ments" of  the  streets  of  Port  Huron,  it  might  be 
supposed,  would  naturally  tend  to  foster  the  epidemic. 
But  the  real  reason  for  the  immunity  was,  doubtless, 
the  dwellings  for  the  most  part  were  confined  to  a 
sandy  or  loamy  porous  soil  overlying  a  substratum  of 
blue  clay,  the  latter  with  a  dip  of  from  twenty  to 
thirty  feet  to  the  mile,  sloping  toward  the  St.  Clair 
River.  Sarnia  and  St.  Clair  both  rest  on  an  out- 
cropping of  clay  that  was  baked  and  seamed  by  the 
hot  sun  of  a  summer  supervening  upon  a  wet  spring. 

Again,  on  November  9th,  181 7,  cholera  attacked 
the  camp  of  the  East  India  Company  troops  stationed 


—  ir- 
on the  borders  of  Scindia;  this  cantonment  was  on 
the  n'g/ithank  of  the  Sindh  or  Betwa  river;  but  the 
ravages  were  stayed  as  by  magic  when  the  forces 
were  moved  over  to  the  /e/t  bank,  a  distance  of  not 
more  than  three-eighths  of  a  mile. 

It  is  also  interesting,  in  this  connection,  to  know 
that  in  India,  in  1819,  the  citadel  of  Jaragurth,  situated 
in  a  slight  depression  1,000  feet  above  the  level  of  the 
plain,  lost  many  of  its  inhabitants,  while  a  city»near 
the  foot  of  the  mountain,  with  good  natural  drainage, 
entirely  escaped  attack ! 

Another  peculiarity  more  or  less  positive  in  its 
evidence  is,  that  while  certain  districts  are  exempt 
during  any  one  epidemic,  or  any  series  of  epidemics, 
the  same  may  on  a  subsequent  occasion  be  attacked, 
though  there  is"  always  a  decided  predilection  for 
some  localities  at  all  times.  It  is  not  uncommon  to 
find  the  epidemic  passing  over  large  tracts  of  coun- 
try, with»the  wind  perhaps  in  its  very  teeth,  and  it 
seldom  spreads  itself  on  any  systematic  or  geographi- 
cal plan,  since  it  may  appear  simultaneously  in  regions 
a  thousand  miles  apart. 

Indeed,  nothing  can  be  more  capricious  than  the 
variation  in  the  intensity  of  the  malady  in  different 
places  and  at  different  times,  or  at  different  times  in 
the  same  places.  An  imported  case  may  end  in  a 
local  attack  confined  to  a  single  room  or  single  house; 
even  a  simultaneous  importation  of  a  number  of  cases 
at  different  points  may  exhaust  itself  in  a  number  of 


local  (circumscribed)  epidemics;  while  at  other  times 
a  single  case  suffices  simply  to  produce  a  general  epi- 
demic or  even  a  raging  pestilence.  The  history  of 
different  epidemics  in  large  cities  shows  the  greatest 
variety  of  effect,  according  as  the  cholera  poison 
found  the  conditions  for  development  more  or  less 
suitable. 

And  when  the  disease  is  fairly  established  as  an 
epidemic,  its  spread  in  a  severely  infected  place  is  by 
no  means  general,  or  in  anyway  uniform.  A  row  of 
houses,  a  series  of  streets  or  blocks,  or  perhaps  a  ward 
or  other  section,  becomes  an  epidemic  centre.  Then, 
again,  there  are  individual  room  (or  several  room), 
epidemics,  sometimes  with  a  certain  preference  for 
damp  cellar  lodgings;  or  individual  groups  of  houses 
are  attacked  in  one  street;  often  only  one  side  of  a 
thoroughfare  is  ravaged,  or  out  of  a  series  of  blocks 
perhaps  only  one  complete  square  and  one  or  two 
streets  will  be  visited,  while  all  about  in  the  vicinity 
there  will  only  be,  here  and  there  an  isolated  case,  or 
none  at  all.  Here  is  illustrated  the  combined  effect 
of  importation  and  of  local  fixation  of  cholera  germs 
in  the  ground  or  drinking  water,  in  the  moisture  of 
the  walls,  in  the  damp,  heavy,  musty  air  of  unventi- 
lated  rooms,  and  in  the  emanations  of  sewers;  while 
the  dissemination  is  effected  by  adhesion  of  the  germs 
to  the  washing,  bedding,  vessels,  etc. 

What  the  primary  factor  may  be,  then,  is  un- 
known, but  the  fact  remains  that  the  production  and 


—   19  — 

course  of  the  malady  are  so  greatly  under  the  control 
of  sanitation  that  neglect  of  measures  essential  to  the 
latter,  on  the  part  of  individuals,  and  municipal, 
county,  and  state  authorities,  as  well  as  the  general 
government,  is  little  (if  any),  less  than  criminal. 

Even  without  knowledge  of  essential  cause,  we  are 
perfectly  familiar  with  results  and .  effects,  and  these 
afford  the  text  upon  which  to  work.  We  do  know, 
aside  from  telluric  or  meteorologic  conditions,*  that 


*The  arguments  for  and  against  the  contagious  nature 
of  cholera  are  many  and  varied,  and  some  of  the  positive  are 
the  result  of  misunderstanding  and  misapprehension.  Thus 
certain  German  writers  are  frequently  quoted  as  contagion- 
ists,  when,  in  fact,  more  careful  perusal  of  their  writings 
show  they  are  only  infectionists;  this  error  arises  from  the 
fact  there  is  but  one  term  {Ansteckung)  in  the  German  lang- 
uage to  express  both  conditions. 

Surgeon-Lieut.  Colonel  J.  M.  Cunningham,  Health 
Commissioner  of  India,  who  for  years  has  studied  cholera 
where  it  is  endemic,  emphiatically  declares  it  is  not  con- 
tagious. Dr.  Edward  Goodeve,who  likewise  has  had  ex- 
tended experience  in  various  portions  of  the  Orient,  insists 
the  malady  "does  not  spread  from  the  sick  to  the  well  by 
any  rapidly  acting  emantion.  Surgeon-General  Chas. Hunter, 
in  his  report  upon  the  epidemic  in  Egypt  in  1884,  is  equally 
assured  of  its  non-contagious  nature.  Many  others  have 
noted  that  patients  ill  with  the  disease  may  be  attended, 
washed,  lifted,  etc.,  with  very  little  risk,  and  that  the  dis- 
charges from  stomach  and  bowels  are  the  chief,  if  not  the 
only,  sources  of  danger.  Hermann  Lebert  pointedly  remarks 
(Ziemssen's  "  Cyclopoedia,  of  the  Practice  of  Medicine,"  vol.  i): 


the  disease,  though  not  in  strict  sense  contagious,  dur- 
ing epidemic  times  is,  in  considerable  degree,  at  least, 
infectious,  the  poison  apparently  being  constant  in  the 
dejections  of  cholera  patients;  that  this  poison  may 
be  disseminated  at  points  remote  from  the  ravages  of 
the  malady  by  being  carried  thither  in  the  intestines 
of  individuals,  who  perhaps  present  no  evidences  of 
cholera  other  than  a  slight  intestinal  flux,  hence  have 
no  idea  they  are  victims,  or  being  made  involuntary 
means  of  communication;  a  transient  traveler  may 
thus,  through  a  single  privy  or  water-closet,  infect  a 
whole  community. 

Niemeyer    tells  us  that   in  1848  a    detatchment 


"Cholera  can  be  spread  only  by  contagion,  that  is  by 
germs  which  are  carried  from  a  diseased  to  a  healthy  per- 
son; but  these  germs  infect  only  comparatively  rarely  by 
intercourse  or  contact  with  cholera  patients,  since  they  pos- 
sess relatively  but  little  vitality  in  the  air  of  the  sick-room, 
and  are  present  mostly  in  inconsiderable  quantity.  On  the 
other  hand,  a  certain  number  of  the  germs  and  a  given 
vitality  are  necessary  for  the  propagation  of  the  disease,  and 
these  conditions  are  better  met  in  fluids  than  in  the  air; 
hence  contagion  is  more  frequent  when  the  germs  are  com- 
municated through  a  fluid  than  when  transmitted  through 
the  air." 

Thus  it  seems,  while  Lebert  apparently  pronounces  for 
contagion,  he  really  means  what  in  English  would  be  infec- 
tion. Felix  von  Niemeyer  ("  Text  Book  of  Practical  Medi- 
cine," vol.  ii.)  expresses  himself  in  like  manner,  and  subse- 
quently adds  he  is  a  non-contagionist,  later  explaining  his 
position,  making  him  in  fact  Siuinfectionist. — S. 


of  recruits  from  Stettin,  where  cholera  was  raging, 
came  to  Magdeburg,  two  of  whom  on  the  night  of 
their  arrival  fell  ill  of  the  malady,  and  were  immedi- 
ately sent  to  the  military  hospital  without  coming  in 
contact  with  the  inhabitants.  Nevertheless,  a  few 
days  later  cholera  asserted  itself  first,  in  the  house 
where  they  had  sojourned  a  few  brief  hours,  and  later 
along  the  street  on  which  the  dwelling  was  situated — 
all  from  the  use  of  a  privy  by  one  of  the  unfor- 
tunates. Again  he  remarks:*  "A  small  epidemic 
in  Greifswald  gave  me  excellent  opportunity  for 
observing  the  spread  of  cholera,  and  in  almost 
every  case  I  could  find  that  the  patients  had  used  the 
privy  of  affected  houses,  or  that  they  had  used  a  privy 
in  common  with  persons  from  these  houses  who  had 
diarrhoea." 

F.  D.  Alexandre  tells  of  a  soldier  attacked  with 
diarrhoea,  who  arrived  at  the  village  of  Haime,  from 
Paris  where  cholera  was  raging,  April  4th,  1849,  and  re- 
mained three  days  at  his  father's  house,  when  he  went 
to  hospital — there  was  no  supposition  of  cholera  in 
his  case,  so  light  was  the  attack:  In  the  course  of 
ten  days  seven  persons  in  the  household  contracted 
the  malady,  four  of  whom  died.  Fred'k  Wm.  Goer- 
ing  corroborates  with  an  account  of  a  vagabond,  suf- 
fering in  like  manner,  who  was  committed  to  the 
workhouse  at   Dieburg,  with  the  result  the  epidemic 

*"  Text-Book  of  Practical  Medicine,"  vol.  ii.  New 
York,  1884. 


swept  through  that  institution,  but  nowhere  else  man- 
ifested itself  in  the  town,  save  in  a  single  instance; 
the  exception  was  the  woman  who  acted  as  laundress 
to  the  prison. 

Also,  Prof,  von  Pettenkofer  relates  the  case  of  a 
man  committed  to  the  prison  of  Ebrach,  from  Munich, 
during  the  existence  of  cholera  at  the  Bavarian  capi- 
tal, and  who  suffered  from  intestinal  flux.  His  diar- 
rhoea persisted,  though  its  nature  was  not  recognized, 
and  he  was  sent  to  prison  hospital.  Immediately  the 
epidemic  developed  within  the  institution,  the  first 
victim  being  a  female  prisoner  who  had  washed  the 
clothing  soiled  with  the  diarrhoeal  discharges  of  the 
Munich  convict. 

Of  the  pernicious  effects  of  general  or  common 
latrines  may  he  cited  the  fact  that,  during  epidemics 
in  America,  the  soldiers  of  the  U.  S.  Army  and  of  the 
Marine  Corps  suffered  more  severely  than  any  other 
relative  number  of  people;  the  closets  or  privies  in 
connection  with  barracks,  are  usually  in  a  foul  state, 
and  in  most  instances  are  merely  open  trenches  with 
but  a  rude  shelter  to  protect  from  the  weather. 

Since  it  has  been  shown  that  the  malady  is  only 
transferred  to  healthy  persons — persons  possessing  no 
special  or  abnormal  receptivity — through  the  dejec- 
tions of  those  afflicted  with  the  disease,  the  previously 
enigmatical  and  apparently  contradictory  observations 
concerning  the  spread  of  an  epidemic  are  satisfactorily 
explained.    Further,  that  it  spreads  more  rapidly  than 


formerly  is  accounted  for  by  the  fact  the  facilities  for 
travel  and  communication  are  greatly  increased;  and 
it  is  little  wonder  the  generally  traveled  routes  ex- 
hibit the  greatest  ravages,  or  that  extension  is  against 
wind,  or  by  long  leaps  with  occasional  retrocessions, 
while  places  intervening  escape — traveling  cholera- 
victims  infect  only  those  places  where  they  leave  their 
dejections.  Again,  if  the  cholera  germs  were  contained 
only  in  the  dejections  of  those  who  suffer  from  the 
severest  form  of  the  disease,  as  they  cannot  travel, 
long  springs  of  cholera  epidemics  could  only  occur 
through  spontaneous  generation,  or  when  persons 
infected  with  the  poison  traveled  during  the  period 
of  incubation,  and  the  disease  in  them  did  not  assert 
itself  en  route.  But  besides  such,  numerous  examples 
prove  that  persons  suffering  from  simple  choleraic 
diarrhoea  (as  in  the  Magdeburg  cases  cited  by  Nie- 
meyer)  and  who  at  no  time  are  very  ill,  carry  with 
them  the  fatal  germs,  and  by  infecting  a  single  water- 
closet  or  out-house  may  start  an  epidemic  de  novo, 
as  it  were. 

Lebert  believes  even  a  healthy  person  may  carry 
the  germ  from  locality  to  locality,  and  yet  suffer  no 
inconvenience— ?>.,  he  may  escape  the  malady  alto- 
gether. He  calls  attention  to  the  fact  one  seizure  also 
renders  individuals  in  some  degree  personally  immune, 
though  their  aptitude  for  carrying  the  infection  is  in 
no  way  lost  providing  they  have  been  exposed  to  its 
influence.      While    he    declares    his    doubt    whether 


—    24    — 

the  cause  is  an  organic  poison  or  living  organism, 
he  is  inclined  to  accept  the  mycetic  theory  which,  as 
he  remarks,  "  explains  without  strained  effort  why  it 
is  that  fluids,  and  especially  stagnant  fluids,  contain- 
ing more  or  less  organic  nutritious  matter,  are  chief 
vehicles  of  the  cholera  germs,  as  they  are  of  all  proto- 
mycetic  forms.  It  is  on  this  account  that  the  water 
of  the  soil,  the  drinking  water,  and  every  fluid,  play 
so  highly  important  a  role  in  the  diffusion  of  the  dis- 
ease; and  yet  neither  the  ground  water  or  the  drink- 
ing water  theories  can  ever  prevail  in  sole  soverignty 
as  causes  of  the  disease,  since  such  are  not  necessary 
for  the  development  of  the  germs,  but  only  become 
so  when  they  can  furnish  these  germs  with  proper 
nutritious  matter,  when  other  favorable  conditions  of 
growth  are  presented,  and  when  more  especially  the 
way  of  communication  with  the  human  organism  is 
open.  The  germs  of  cholera  may  be  spread  without 
ground  or  drinking  water  just  as  easily  as  with  them, 
through  the  air,  by  becoming  attached  to  solid  bodies, 
etc.  .  .  .  True,  cholera  finds  in  drinking  water 
also  a  very  frequent  and  most  potent  medium  of  dis- 
semination, as  it  may  be  impregnated  with  the  poison 
(from  water  of  the  soil  by  filtration  from  privies  and 
sewers)  which  may  then  flourish  in  further  develop- 
ment; still  drinking  water  alone  cannot  be  considered 
as  the  exclusive  or  necessary  means  of  dissemination. 
Over- flowing  or  badly  cemented  drainage  or  sewer 
pipes,  for  instance,  conveying  infectious  matter,  may 


—  25  — 
carry  their   foul    contents   directly    into   the  ground 
walls  of  cellars,  and  dwellings,  and  swiftly  develop 
destruction  among  the  inhabitants." 

It  is  probable,  however,  the  dejections  do  not 
when  first  expelled  contain  the  cholera  germs  in 
the  stage  of  development  necessary  to  infection,  but 
that  they  become  strictly  aggressive  only  after  hav- 
ing undergone  fermentation,  which  result  is  furthered 
by  admixture  with  decomposing  animal  substances — 
and  this  is  why  the  midden  privy  is  always  a  greater 
source  of  danger  than  the  modern  closet.  This 
theory  is  supported  by  numerous  facts. 

Dr.  O.  D.  Norton,  a  veteran  practitioner  of  Cin- 
cinnati, who  had  extended  experience  with  chol- 
era in  the  epidemic  of  1849,  remarks,  regarding  ex- 
periments with /Vr^-^  alvine  excretions  of  "rice-water" 
character,  that  he  and  a  confrere  fed  such  by  buckets- 
full  to  numerous  chickens  and  pigs,  but  induced  in 
them  no  evidences  of  the  disease;  on  the  contrary, 
these  creatures  seemed  to  "grow  fatter  "  thereon.* 

The  observations  of  C.  von.  Thiersch  show  that 
while  recent  dejections  are  not  dangerous  to  animals, 
feeding  the  same  with  old  excreta  of  the  same  sort 
invariably  induces  the  malady,  f 

Further,  experience  shows  that  physicians  passing 


*  Cincinnati  Lancet-Clinic,  vol.  xxiv;  Sept.  24th,  1892. 

f'Meine  Cholera-Infectionsversuche  vom  Jahre,  1854, 
und  die  des  Herrn  Dr.  B.  J.  Stokvis  vom  Jahre,  1866." 
Munich,  1867. 


—     26    — 

from  bedside  to  bedside  are  comparatively  immune. — 
Niemeyer  says  his  experience  in  cholera  epidemics, 
wherein  he  wrapped  patients  in  blankets  and  often 
held  them  in  his  arms  for  some  time,  made  him  a 
"decided  anti-contagionist;"  that  those  who  wash  the 
body  and  bed  linen  after  they  have  lain  some  time, 
are  more  apt  to  be  infected  than  those  who  directly 
care  for  the  patient,  even  to  removing  the  dejecta. 

Again,  Lebert  says:  "  I  have  noticed  in  all  epi- 
demics, and  have  seen  it  mentioned  in  the  writings  of 
many  authors,  that  practicing  physicians,  even  hospital 
physicians,  are  seldom  attacked  with  cholera." 

In  Cairo,  Egypt,  in  1831,  of  one  hundred  servants 
employed  as  rubbers  or  masseurs  of  cholera  patients, 
not  one  was  ever  attacked;  of  eighty  rubbers  at  the 
hospital  at  Mansurah,  and  sixty  at  Damietta,  all 
escaped  save  one.  None  of  the  physicians  or  nurses 
of  the  cholera  service  at  Constantinople  in  1855-56, 
and  Oran  in  r86i,  ever  suffered  from  any  form  of 
the  disease. 

Washerwomen,  whenever  they  wash  linen  soiled 
with  cholera  dejections,  without  any  precautions,  are  at- 
tacked in  all  places  in  no  small  numbers.*  In  Branson, 


*The  frequency  with  which  washerwomen  fall  ill  with 
the  disease  from  contact  with  infected  linen  has  often  been 
mentioned,  but  there  are  also  examples  where  cholera  has 
been  spread  by  rags  and  other  objects.  The  same  is  true  in 
still  higher  degree  of  unclean  bedding.  C.  von  Zehnder 
ascribes  the  origin  of  two  cholera  centres  in  the  Ziirich  epi- 


—    27    — 

in  the  Canton  of  Valais  (Switzerland),  in  1867,  one  of 
the  Sisters  of  Charity  nursed,  with  the  greatest  self- 
sacrifice,  all  the  cholera  patients  in  very  filthy 
chambers,  and  yet  remained  healthy,  but  at  the  close  of 
the  epidemic  "  her  sympathy  prompted  her  to  assist  in 
washing  up  the  soiled  linen,  when  she  was  attacked 
with  the  disease  and  died.  It  was  from  a  washer- 
woman, who  died  after  washing  the  clothes  of  a 
cholera  fugitive,  that  the  epidemic  developed  later  in 
Zurich,  1867."     (Lebert.) 

Very  numerous  facts  might  be  cited  to  demon- 
strate that  cholera  may  be  communicated,  and  carried 
from  place  to  place,  by  clothing  or  other  material 
soiled  by  cholera  dejections;  the  observations  of 
Etienne  Moulin,  Gaston  Pellissier,  Jas.  Simpson, 
Jules  Bucquoy,  J.  M.  and  D.  D.  Cunningham,  Max  von 
Pettenkofer,  Antoine  Fauvel,  Augusto  Guastella,  and 
others,  are  most  definite.  Guastella  remarksrf  "■  There 
were  persons  living  in  places  sheltered  from  the  epi- 
demic who,  after  washing  linen  soiled  with  the  dejec- 
tions of  cholera,  carried  the  disease  afar."  Fauvel 
adds  other  f  actsj  showing  that  camping  places  where  an 

demic  of  1867  to  an  accumulation  of  bedding,  mattresses, 
pillows,  etc.,  that  had  been  used  on  the  beds  of  cholera 
patients,  and  afterwards  piled  up,  before  being  carried  off 
for  disinfection,  in  the  neighborhood  of  the  houses  affected. 
— S. 

•f"  D'  igiene  e  medicina  navale  ad  uso  della  marina 
merchantile."     Trieste,  1861. 

I"  Le  Cholera;  etiologie  et  prophylaxie."     Paris,  1868. 


—    28    — 

epidemic  has  occurred,  hospital  wards,  sick  chambers, 
ships  and  cars  carrying  cholera  patients,  etc.,  may 
preserve  for  some  time,  under  certain  circumstances, 
the  power  of  transmitting  the  disease;  nevertheless, 
such  examples  are  comparatively  rare.  To  transmit 
cholera  by  clothing,  he  considers,  demands  certain 
conditions,  viz.:  "To  transport  it  a  short  distance 
requires  certain  contact  with  objects  in  connection 
with  the  patients,  especially  those  soiled  by  vomit  and 
rectal  discharges;  to  transport  long  distances,  the  ob- 
jects previously  exposed  to  contact  must  be  confined 
to  close  quarters  where  the  fresh  air  is  not  renewed, 
and  where  sunlight  does  not  enter.  There  are  few 
examples  of  objects  freely  ventilated  carrying  the 
disease  for  any  long  time,  or  long  distance,  while 
there  are  many  cases  to  prove  that  the  transmission 
may  easily  occur  where  soiled  effects  have  been 
closely  packed  for  several  months." 

As  to  the  influence  of  dead  bodies  in  disseminat- 
ing infection  directly — i.  <?.,  by  handling, —  Lebert 
expresses  himself  as  doubting  it  very  much.  "We 
occupied  ourselves  almost  daily  in  Paris,  in  1849 — 
my  friends  and  myself — with  investigations  into  the 
pathological  anatomy  of  cholera.  In  Zurich,  in  1855, 
I  made  all  the  post  mortem  examinations,  with  my 
assistant.  Dr.  Wegelin,  and  neither  of  us,  and  no  one 
of  our  dead-room  attendants,  were  attacked  with  the 
disease.  I  consider  it,  therefore,  merely  an  accident 
when    a  body-carrier  falls  sick.      I  believe,   indeed, 


—    29    — 

-that  animal  putrefaction  rather  diminishes  the  capacity 
for  infection,  and  that  the  bacteria  of  decomposition 
destroy  the  germs  ot  cholera." 

Hugo  Wilhelm  von  Ziemssen*  lays  especial  stress 
upon  the  fact  "  it  is  more  dangerous  for  the  persons 
in  a  house  if  the  evacuations  are  emptied  into  a  privy 
filled  with  excrement,  into  a  cess-pool,  or  thrown  on 
a  dunghill,  as  in  such  places  the  germs  seem  to  find 
circumstances  most  favorable  to  their  development 
and  increase." 

A.  von  Hirschf  insists  marshy  and  malarial  re- 
gions are  especially  favorable  to  the  dissemination  of 
cholera,  in  that  they  furnish  nourishment  for  the 
germs,  favoring  their  multiplication;  also  because 
the  soil  in  such  localities  is  eminently  fitted  to  trans- 
mit, by  soaking  and  slow  filtering,  cess-pool  fluids  and 
sewage  waste,  carrying  into  cellars  and  basements; 
that  thus  the  privy  of  a  neighbor  may  be  more  dan- 
gerous than  one's  own,  especially  if  in  close  prox- 
imity to  the  residence  of  the  latter. 

From  observations  made  during  the  last  three 
epidemics  in  France,  Dr.  Hippolyte  Mireur  concludes 
cholera  is  not  transmitted  directly  from  the  ill  to  the 
well  by  contact  or  through  the  respiratory  passages; 
that  the  products  emanating  from  cholera  patients — 


*  "  Die  Choleraepidemie,  vom  Jahre  1867."  Greifswald, 
1870. 

f  "  RUckblickauf  die  neuereCholeralitteratur."  Schmidt's 
JahrbUcher.     Bd.  Ixxxviii. 


—  3°  — 
the  dejections  and  vomited  matters — alone  contain 
the  germs,  which  are  not  immediately  transmitted  by 
themselves,  but  when  placed  under  favoring  condi- 
tions give  rise  to  an  infectious  principle;  that  cloth- 
ing and  merchandise, — such  as  skins,  hides,  rags,  etc. 
— much  more  than  individuals,  are  the  agents  for  the 
transportation  of  this  principle.  * 

If  then  there  is  any  justice  in  the  belief  of 
Lebert,  Hirsch,  et  al.,  that  the  cholera  germ  lies 
within  a  spore,f  it  is  more  than  probable  the  ripening 
of  such  in  the  faeces  after  evacuation  is  the  real 
source  of  infection;  or  that  the  product  of  the  ripened 
spore,  on  being  returned  to  an  economy,  further  de- 
velops producing  perhaps  certain  alkaloids  that,  in 
turn,  taken  up  by  the  absorbents,  induce  violent  toxic 
symptoms — symptoms  that,  made  manifest  through 
the  nervous  system,  constitute  the  phenomena  of  the 
disease.  Dr.  Thos.  King  Chambers  remarks:J  "  There 
is  every  reason  to  believe  the  chief  exciting  cause  of 
the   disease  is   a  poison  generated  by   decomposing 


*"  Etude  historique  et  pratique  sur  la  prophylaxie  et  le 
traitement  du  cholera,"  etc.     Paris,  1884. 

fThe  question  of  a  spore  is  an  interesting  one  from  a 
certain  standpoint  since  the  majority  of  observers  of  and 
believers  in,  deny  such  to  the  comma  bacillus;  yet  Huppe,,  of 
Prague,  declares  this  germ  does  possess  "a  fructification 
propensity  by  virtue  of  an  arthrosporulation,"  which  he 
personally  observed. — S. 

I  "  The  Renewal  of  Life;  Lectures  Chiefly  Clinical." 
London,   1864. 


—  31  — 
organic  matter  and  received  into  the  body  from  with- 
out. To  judge  by  its  effects,  it  seems  widely  diffused 
through  the  air,  especially  in  the  neighborhood  of  its 
origin— in  the  air  of  privies,  cess-pools,  sewers,  putrid 
marshes,  and  crowded  human  habitations.  One  is 
perhaps  tempted  to  ask  how  it  is,  if  the  poison  is 
spread  so  broadcast,  that  everybody  does  not  get  poi- 
soned; but  it  must  be  remembered  two  things  are 
necessary  to  poisoning,  viz.:  Not  only  a  poison,  but 
a  person  in  condition  to  be  poisoned;  and  in  point 
of  fact  the  latter  is  the  more  important  element  in  the 
transaction." 

Thus  the  weight  of  evidence  goes  to  show  chol- 
era epidemics,  for  existence  and  dissemination,  demand 
three  prime  factors,  viz.: 

First.  Conditions  of  soil,  atmosphere,  etc.  (gen- 
eral surroundings),  favorable  to  the  nourishment  of 
the  germ  or  germs,  which  would  otherwise  speedily 
lose  the  power  of  infecting: 

Second.  Conditions  in  each  human  subject,  indi- 
vidually, favoring  receptivity  : 

Third.  Direct  infection /^r.y<?.- 

And  regarding  the  last,  it  is  believed  the  princi- 
pal, if  not  the  only  way  of  insuring  infection,  is 
through  the  medium  of  the  intestinal  canal  and  its 
absorbents: 

That  the  germs  are  ordinarily  carried  but  a  short 
distance  through  or  by  the  air: 

That  the  great  danger  lies  with  the  alvine  evacu- 


—    2,2    — 

tions  and  vomited  matters,  but  only  after  fermenta- 
tion has  been  set  up  therein: 

That  contamination  of  the  water  supply  and  of 
food,  by  cholera  discharges,  is  ever  a  grave  factor: 

And,  finally,  that  linen,  cotton,  or  woollen  fab- 
rics, soiled  by  cholera  discharges,  if  excluded  from 
air  and  sunlight,  serve  to  keep  alive  the  germs  of  the 

disease  for  an  indefinite  period. The  history  of  the 

barque  Swanton,  on  which  cholera  did  not  appear 
until  she  had  been  at  sea  for  twenty-seven  days, 
when  clothing  was  unpacked  by  the  passengers,  alsO' 
of  the  ship  JVew  York,  on  which  the  disease  did  not 
manifest  itself  until  she  was  sixteen  days  out  from 
her  port  of  departure,  and  then  under  the  same  cir- 
cumstances as  on  board  the  Swanton,  both  evidence 
the  truth  of  this  statement. 


CHAPTER  III. 

TRANSMISSION    DANGERS. 

It  is  to  Prof,  von  Pettenkofer  we  are  indebted  for 
the  discovery  that  porosity  of  the  soil,  by  enabling  the 
contents  of  privies  and  cess- pools  containing  the  chol- 
era germs  to  freely  permeate  and  soak  the  ground  for 
some  distance  around,  and  poison  wells  and  sewers, 
favors  the  rapid  extension  of  the  disease,  while  the 
opposite  quality  to  some  extent  inhibits  dissemination; 
and  the  same  author  was  the  first  to  demonstrate  that 
the  "  manifest  fitness  of  any  locality  for  the  disease 
depends  on  excrement,  containing  the  germs,  perme- 
ating the  soil  and  exposed  to  circumstances  favorable 
to  decomposition." 

Next  to  soaking  of  the  soil  is  the  danger  from  gut- 
ters and  drains,  which  may  carry  the  infection  from 
house  to  house;  and  it  is  well  known  that  a  soil-pipe, 
or  untrapped  rain-gutter,  has  carried  the  disease  into 
an  uninfected  dwelling  through  a  window  of  the  latter 
being  contiguous  to,  and  at  higher  elevation  than,  the 
upper  end  of  the  latter. 

There  can  be  no  doubt  foul  drinking  water  plays 
no  inconsiderable  role  in  dissemination.  Mr.  J.  Snow* 
established  the  connection  of  the  fearful  local  epi- 


*"  Cholera  and  the  Water  Supply  in  the  South  Districts 
of  London  in  1854."  London,  1856. 


—  34  — 

demic  in  Broad  street,  St.  James'  Parish,  London,  in 
1854  with  an  infected  well;  its  ravages  ceased  when 
this  supply  of  water  was  shut  off  from  the  public.  J. 
Simon*  declares  in  the  portion  of  London  supplied 
with  river  water  drawn  from  the  stream  after  it  had 
received  the  contents  of  a  large  number  of  sewers,  so 
that  it  had  forty-six  grains  of  solid  constituents  to  the 
gallon,  the  number  who  succumbed  to  the  malady  was 
thirteen  out  of  every  thousand,  while  in  other  situa- 
tions, under  precisely  parallel  circumstances  and  sur- 
roundings, save  the  water  supply  contained  but  thirteen 
grains  of  solids  to  the  gallon,  the  death  rate  was  only 
3.7  per  1,000.  Edward  Frankland,f  speaking  of  the 
same  city  and  relation  of  water  supply  to  cholera, 
says: 

"  On  the  i8th  of  August,  1866,  a  family  removed 
from  London  to  Margate;  on  the  26th  there  was  a 
storm  with  heavy  fall  of  rain,  and  the  water  had  an 
unusual  odor  and  taste.  On  the  27th  four  persons 
were  attacked  with  cholera,  and  on  the  following  day 
still  more,  the  most  of  whom  died.  The  water  in  the 
well  at  the  end  of  the  garden  furnished,  in  100,000 
parts,  93.4  of  solid  matters,  of  which  7.36  parts  were 
of  organic  or  volatile  nature.  The  cess-pool  adjoin- 
ing the  garden  had   clearly   poured   its  contents  into 


*"  Report  on  the  Two  Last  Cholera  Epidemics  as  Af- 
fected by  the  Consumption  of  Impure  Water."  London,  1856. 

f "  The  Water  Supply  of  London  and  the  Cholera." 
Quarterly  Journal  of  Science,  1867. 


—  35  — 
the  well  after  the  overflow  caused  by  the  rain,  and 
this  had  caused  the  fatal  contamination,  for  an  anal- 
ysis made  Sept.  i8th  showed  82.75  solids  (in  100,000), 
of  which  but  1.13  parts  were  of  organic  or  volatile 
nature.  Is  was  proven  that  all  who  were  attacked 
had  drank  from  the  well.  A  similar  occurrence  was 
established  by  Dr.  Lancaster,  of  Epping  Forest." 

The  same  author  declares  the  inhabitants  of 
London  who  used  Thames  water  from  Kew,  above 
the  city,  showed  a  mortality  from  cholera  of  but  8  in 
10,000;  those  who  used  the  water  from  Hammer- 
smith, 17  in  10,000;  from  Battersea  to  Waterloo 
Bridge — that  is  water  contaminated  by  the  sewage  of 
the  city — 163  in  10,000.  In  1854  only  the  half  of  a 
district  was  supplied  from  Teddington  Loch,  and  the 
mortality  therein  was  87  in  10,000,  but  in  1866,  all  the 
water  in  the  Loch  having  been  drawn  off,  the  mor- 
tality was  less  than  one-tenth  of  that  in  1854.  Again, 
in  1866  the  cholera  was  very  severe  in  the  East  End, 
which  was  supplied  by  the  East  London  Water  Com- 
pany, from  Oldford,  the  reservoir,  on  the  river  Lee, 
being  little  better  than  an  open  excrement  and  sewer 
receptacle,  even  filtration  being  neglected.  The  re- 
sult was  the  mortality  in  this  portion  of  the  city 
was  from  63  to  112  per  10,000,  while  the  balance  of 
the  London,  with  a  pure  water  supply,  exhibited  a 
death  rate  of  only  2  to  12  per  10,000. 

Manchester  suffered  terribly  from  cholera  in  1832 
and  1849,  when   the  water  supply  was  very  impure, 


-  36  - 

but  in  1854  and  1866,  the  water  being  derived  from 
the  interior  of  Derbyshire  through  an  aqueduct,  there 
were  very  few  cases,  and  these  only  of  a  sporadic 
character. 

Dr.  W.  Schiefferdecker,  too,  mentions  a  fact 
worthy  of  note  concerning  the  six  great  cholera  epi- 
demics that  ravaged  Kpnigsberg,  Prussia,  from  1831 
to  1866,  in  which  more  than  2500  people  succumbed 
out  of  nearly  six  thousand  attacked.*  The  inhabi- 
tants of  those  portions  of  the  city  supplied  with  drink- 
ing water  from  the  river  Pregel,  and  from  wells,  were 
those  that  suffered  most,  while  those  supplied  by  a 
system  of  water-works  from  the  so-called  "  upper 
tank,"  in  which  the  water  was  exceedingly  pure,  suf- 
fered much  less  severely;  the  Pregel  and  wells  were 
fed  with  ground  water  and  sewage. 

Dr.  J.  Gratzer  also  describes  an  instance  occur- 
ring in  Breslau  during  the  epidemic  of  1867,!  in  which 
the  walls  of  a  badly  constructed  privy  attached  to  a 
newly  built  and  well  arranged  house  rendered  the 
water  in  an  adjacent  well  impure;  besides,  the  privy 
vault  was  not  regularly  emptied,  and  its  contents 
overflowed  into  an  unwalled  excavation  in  the  neigh- 
borhood of  a  large  accumulation  of  ground-water. 
The  consequence  of  this  contamination,  which  affected 
the  drinking  water  was,  that  in  the  beginning  of  the 

"*Die  Choleraepidemie  vom  Jahre  1871  in  Konigsberg."^ 
Konigsberg  1873. 

f  "  Die  Breslauer   Cholera-Epidemic."     Breslau  1873. 


—  37  — 
epidemic  no  less  than  twelve  of  the  inhabitants  of  the 
house  were  attacked,  eleven  of  whom  died;  also  other 
persons  in  the  vicinity,  who  obtained  water  from  the 
same  well,  were  seized.  In  this  instance,  it  was 
proved  the  cholera  poison  first  entered  the  privy, 
thence  passed  into  the  ground  water,  then  into  the 
drinking  water,  and  so  on  into  the  digestive  organs  of 
the  unfortunates. 

Again,  when  cholera  is  once  introduced  it  some- 
times happens  only  those  are  attacked  who  are  in  the 
house  where  the  first  infection  is  received,  or  who 
visit  the  same  closet;  and  in  some  instances  the 
malady  has  been  restricted  solely  to  house  epidemics 
— further  illustration  of  the  care  that  should  be 
exercised  in  the  way  of  sanitation. 

Niemeyer  believes  the  poison  is  rarely  taken  into 
the  system  in  the  drinking  water,  but  in  the  main  enters 
the  economy  during  the  act  of  respiration  and,  lodg- 
ing in  nose,  mouth,  or  throat,  is  swallowed  with  the 
saliva.  "  Using  infected  privies  is  so  dangerous,  be- 
cause they  are  the  favorite  lurking-places  of  cholera 
germs,  and  the  gases  arising  always  contain  dust-like 
particles."  The  poison  passes  from  the  closet  to  the 
dwelling,  and  A.  Biermer  insists  the  latter  are  "  more 
liable  than  individuals  to  infect." 

So  far  I  have  said  nothing,  relatively,  regarding 
the  claims  of  two  schools  the  members  of  one  of 
which,  like  sheep,  blindly  follow  their  bell-wether  over 
any  obstruction  regardless  of  cause  or  reason.     First 


-  38  - 

of  these  stand  the  followers  of  Louis  Pasteur — a 
visionary  whose  utterances  have  never  been  worthy 
of  dependence,  who  is  utterly  devoid  of  physio- 
logical or  other  medical  knowledge,  and  who,  more- 
over, is  not  even  a  reputable  chemist — the  bacil- 
lary  pathologists.  Second,  those  walking  in  the  foot- 
steps of  Francesco  Selmi  and  Armand  Gautier,  the 
latter  of  whom  stands  first  in  the  discovery  and 
investigation  of  vital  alkaloids,  and  has  had  courage 
to  approach  some  problems  of  physiology  and  pa- 
thology most  abstruse  and  complex  in  nature,  open- 
ing up  a  wide  territory  that  has  hitherto  escaped 
investigation.  It  might  be  added  there  is  a  third 
coterie,  who,  between  the  "devil  and  the  deep  sea," 
have  appeared  anxious  to  reconcile  the  foregoing,  and 
by  blending  the  two  evolve  a  new  pathology,  Eman- 
uel Klein,  perhaps,  being  the  most  able  representa- 
tive of   the  class. 

Practical  medicine  has  suffered  much  from  the 
invasion  of  new  theories  as  well  as  experimental 
methods;  traditional  pathology  has  given  way  to 
the  experimental,  and  spontaneous  maladies  to  those 
forms  that  may  be  artificially  provoked  in  inferior 
creatures.  Further,  the  upholders  of  bacteriological 
pathology  have  followed  too  closely  in  the  steps  of 
their  masters,  in  that  they  sedulously  ignore  all  nega- 
tive evidence  while  magnifying  the  positive.  For  in- 
stance, the  monumental  report  on  cholera  just  issued 
from  the  Government  press  at  Washington,  was  com- 


—  39  — 
piled  by  an  ardent  bacteriologist,  who,  while  gather- 
ing everything  favorable  to  his  view,  carefully  ex- 
cluded all  evidence  calculated  to  invalidate;  he  quotes 
the  early  reports  of  Surgeon-Major  D.  D.  Cunning- 
ham, which  are  indefinite,  and  sedulously  ignores 
the  later  investigations  of  the  same  author  as  well 
as  those  of  Surgeon-General  Wm.  R.  Cornish,  Sur- 
geon-Major Timothy  R.  Lewis,  Professor  Ray  Link- 
ster.  Sir  Wm.  Aitken,  Doctor  A.  N.  Brown,  et  al. 
— an  act  which  renders  the  "sin  of  omission  "even 
greater  than  that  of  commission.  Etiology,  theoreti- 
cally, has  been  very  much  simplified  by  the  discovery 
of  microbes,  but  certainly  scientific  medicine  has 
very  little  profited  thereby,  since  attention  has  been 
diverted  from  clinical  observation  and  research.  The 
fallacious  charms  of  the  germ  theory  have  caused  med- 
ical men  to  forget  their  mission,  have  prevented  the 
relief  of  the  ill,  and  produced  misconceptions  of  dis- 
ease. Dr.  B.  W.  Richardson  *  only  recently  protested 
against  the  idea  it  was  necessary  "to  subject  a  patient 
to  a  kind  of  modified  snake-bite  in  order  to  settle  a 
question  of  diagnosis,"  and  adds:  "Twenty  years 
ago  the  profession  was  steering  well  and  steadily 
towards  great  principles  on  the  preventive,  as  well 
as  curative  side  of  medicine;  then  crept  in  the  wild 
enthusiasm  of  bacteriological  research  —  research 
good  enough  in  its  way  as  a  piece  of  natural  history, 


*The  Asclepiad,  1891. 


—  40  — 

and  as  disclosing  some  curious  tribal  phenomena 
developed  under  morbid  states  of  the  organic  struct- 
ures and  the  blood,  but  a  positive  insanity  when  ac- 
cepted as  the  one  absorbing  pursuit,  restoring  hu- 
moral pathology,  ignoring  nerve  function,  leading 
to  Babel  with  its  utter  confusion  of  tongues,  and  sep- 
arating for  a  time  the  modern  art  of  cure  from  the 
accumulated  treasures  of  knowledge,  wisdom,  and 
light  of  over  two  thousand  years." 

It  may  here  be  remarked,  likewise,  that  the 
majority  of  maladies  to  which  popular  pathology 
ascribes  bacterial  origin,  are  very  severe  in  character, 
and  most  generally  fatal.  Therefore,  in  cases  where 
dissolution  is  rapidly  impending,  it.  is  not  without  the 
bounds  of  probability  or  possibility — indeed  has  been 
triumphantly  demonstrated  in  many  instances, — that 
partial  death  may  affect  the  fluids  and  tissues  to 
greater  or  less  extent  preceding  the  general  death  of 
the  organism;  that  is  to  say  the  sum  of  the  deaths  of 
the  constituent  elements.  Again,  in  certain  cases, 
changes  usually  observed  post-mortem  may  and  do 
take  place  in  the  fluids  and  tissues,  or  a  portion 
thereof,  ante-mortem — sloughing,  gangrene,  phthisis, 
malignant  diseases,  etc.,  are  evidences  of  this.  Conse- 
quently, bacteria,  which  under  natural  surroundings 
and  habits  of  life  are  ever  the  products  of  decomposi- 
tion, may  be  found  in  the  tissues,  blood,  and  other 
fluids  during  life,  and  be  the  results  merely  of  the 
advanced  decree  of  the  diseased  condition — not  the 


—  41  — 
cause  of  its  development.  And  to  force  inductions  as 
the  result  of  artificial  cultivation  of  microbes,  and  the 
artificial  diseases  induced  thereby,  instead  of  through 
natural  development  of  the  same  and  the  pathological 
factors  under  which  such  development  occurs,  is  not 
alone  contrary  to  all  scientific  precedent,  but  must 
always  remain  a  source  of  error.  Just  as  tame  fruits 
differ  from  the  wild,  and  domestic  creatures  from 
those  that  are  ferx  natura,  so  must  bacilli  differ 
according  to  their  mode  of  cultivation  and  develop- 
ment, and  in  their  results;  a  parallel  under  such  cir- 
cumstances cannot  but  be  fallacious,  as  every  zoolo- 
gist or  botanist  well  understands,  and  a  more  thorough 
knowledge  of  these  branches  of  science,  on  the  part 
of  the  medical  profession,  would  lead  to  fewer  errors 
in  pathological  investigation. 

Again,  Dr.  Burdon-Sanderson's  investigations* 
prove  the  development  of  infective  inflammatory 
products  as  the  result,  purely,  of  chemical  irritants, 
while  Lewis  and  Cunningham  alike  observed  bacteria 
in  the  blood  of  creatures  dying  from  such  experi- 
ments. These  important  facts  have  a  most  pertinent 
bearing  on  the  aetiology  of  cholera,  as  will  be  observed 
in  a  subsequent  chapter. 

In  the  report  of  the  Ger7nan  Cholera  Commis- 
sion dated  Calcutta,  February  2d,  1884,  Koch  an- 
nounced the  comma  bacillus  as  the  specific  cause  of 


*The  Lancet  (London),   voL   i,  1873. 


—  42  — 

cholera;  and  since  his  claimed  discovery  was  based  on 
microscopic  slides  from  four  specimens  of  cholera  in 
natives,  said  slides  being  furnished  by  Surgeon-Major 
T.  R.  Lewis,  the  latter,  in  conjunction  with  Surgeon- 
Major  D.  D.  Cunningham,  deemed  the  matter  worthy 
of  further  investigation.  In  their  report  it  is  re- 
marked:* 

"So  far,  therefore,  the  selection  of  the  comma- 
shaped  bacillus  as  the  materies  morbi  of  cholera  ap- 
pears to  be  entirely  arbitrary.  Dr.  Koch  and  his 
colleagues  have  adduced  no  evidence  to  show  that 
it  is  more  pernicious  than  any  other  microbe;  in- 
deed, as  a  matter  of  fact,  the  sole  argument  of  any 
weight  which  has  been  brought  forward  ...  is 
the  circumstance  it  is  more  or  less  prevalent  in  every 
case  of  the  disease,  and  that  the  German  Cholera  Com- 
mission had  not  succeeded  in  finding  it  in  any  other." 

With  regard  to  the  suggestion  that  the  cholera  pro- 
cess may  in  some  way  favor  the  growth  of  these 
bacilli,  and  that  they  are  not  necessarily  a  cause  of 
the  disease,  Dr.  Koch,  in  the  report  from  Calcutta, 
declares  such  a  view  is  "  untenable,"  inasmuch  as  it 
would  have  to  be  assumed  "that  the  alimentary  canal 
of  a  person  stricken  with  cholera  must  have  already 
contained  these  bacteria;  and,  seeing  that  they  have 
been  invariably  found  in  the  comparatively  large 
number  of  cases  of  the  disease  in  Egypt  and  India,  it 

*"  Physiological  and  Pathological  Researches."  Lon- 
don,  1888. 


—  43  — 
would  be  necessary  to  assume  further,  that  every 
individual  must  harbor  them  in  his  system.  This, 
however,  cannot  be  the  case,  because,  as  already 
stated,  the  comma-like  bacilli  are  never  found  except 
in  cases  of  cholera." 

To  this  Drs.  Lewis  and  D.  D.  Cunningham  reply,* 
if  Koch  and  his  colleagues  had  submitted  the  secretions 
of  the  mouth  and  fauces — the  very  commencement  of 
the  alimentary  canal — to  careful  microscopic  examina- 
tion of  the  same  kind  as  that  to  which  they  have 
submitted  the  alvine  discharges,  "  we  feel  persuaded 
that  such  a  sentence  would  not  have  been  written, 
seeing  that  comma-shaped  bacilli,  identical  in  size, 
in  form,  and  in  reaction  to  anilin  dyes,  with  those 
found  in  cholera  dejecta,  are  ordinarily  present  in  the 
mouth  of  perfectly  healthy  persons." 

Koch  subsequently  admits  he  had  examined  the 
mouth  of  healthy  persons  but  found  no  comma  bacilli; 
on  another  occasion,  as  claimed  by  C.  S.  Dalleyf 
(though  I  can  nowhere  find  such  utterance  in  Koch's 
own  publications),  he  declared  his  familiarity  with  the 
comma  bacillus  of  the  mouth,  and  that  it  differs  from 
his  cholera  bacillus  in  "being  longer,  more  slender, 
and  not  so  blunt  at  the  ends,"  etc.;  but  T.  R.  Lewis, 
Douglas  Cunningham,  Ray  Linkster,  Arthur  E.  Brown, 
and  Sir  Wm.  Aitken  subsequently  proved  the  identity 

*  Ibid. 

f  "Technology  of  Bacteriological  Investigation."  Bos- 
ton, 1885. 


—  44  — 

of  the  organisms  by  accurate  tests  and  measurements 
applied  respectively  to  colonies  taken: 

(a)  From  the  mouth  of  healthy  human  beings 
ranging  from  four  to  fifty  years  of  age: 

(d)  From  the  alvine  discharges  of  cholera-affected 
persons: 

(c)  From  the  intestines  of  persons  who  had  died 
of  cholera: 

(d)  From  cultivations  of  all  three  in  agar-agar 
jelly,  in  weakly  alkaline  peptone  gelatin,  etc.,  and: 

((f)  By  the  reaction  of  all  to  staining  fluids — 
fuchsin,  gentian  violet,  methylen  blue,  etc. 

Further,  during  a  subsequent  and  independent 
investigation,  D.  D.  Cunningham  found  ten  different 
kinds  of  comma  bacilli  in  the  dejections  of  sixteen 
consecutive  cholera  patients,  that  of  Koch  "being 
very  far  from  the  most  numerous  of  the  lot."  Lewis, 
too,  found  the  Koch  bacillus  most  abundantly  in  the 
drinking  waters  of  India  in  the  season  when  the 
people  using  such  waters  were  absolutely  free  from 
cholera.  And  M.  Neller*  observed  the  bacillus  of 
the  present  cholera  epidemic  in  Europe  to  differ 
markedly  from  that  claimed  by  Koch  to  have  been 
discovered  in  India,  in  that  it  is  thicker,  shorter,  and 
larger  than  the  latter,  causes  turbidity  of  bouillon, 
and  in  peptonized  gelatin  grows  more  rapidly;  it  was 
found  in  twenty-nine  cases  of   cholera,  also    in  the 


*Le  Progres  Medicale.    1892. 


—  45  — 
sputum  of  a  case  of  broncho-pneumonia;  and  in  thirty 
additional  cases  of  cholera,  no  comma  bacillus  whatever 
could  be  found. 

The  result  of  these  investigations  conclusively 
prove  the  so-called  cholera-bacillus  to  be  only  an 
"old  friend  under  a  new  name" — an  everyday  spiril- 
lum. 

Again,  the  investigations  of  Pettenkofer,*  Bier- 
mer,  and    others,  are   founded   on    clinical   data   too 


*  Prof,  von  Pettenkofer  who,  together  with  Robert  Koch, 
has  been  actively  engaged  in  studying  and  observing  cholera 
in  the  present  Hamburg  epidemic,  declares  that  the  latter's 
theory  of  the  origin  of  the  malady  "  has  not  stood  the  test  of 
experience."  It  has  not  been  proved  that  the  pestilence  was 
brought  to  the  city  in  the  way  indicated  by  Koch,  or  that  the 
comma  bacillus  is  the  cause  of  the  epidemic.  Commenting 
editorially  upon  this.  The  Lancet  (London)  remarks:  "  One 
of  the  difficulties  attending  the  acceptation  of  the  cholera 
bacillus  theory  of  the  causation  of  cholera  is,  to  account  for 
the  occurrence  of  isolated  and  sporadic  cases  of  that  disease, 
which  in  the  aggregate  amount  to  a  large  number — in  India, 
for  example.  One  man  is  attacked  and  dies  of  cholera  in 
the  barrack  room  occupied  by  a  number  of  others,  the  air, 
food,  water  supply  and  all  other  conditions  being  the  same 
for  all  alike.  There  is  perhaps  no  other  case  of  cholera  in 
the  station  at  the  time,  nor  is  there  any  history  of  any  hav- 
ing occurred  before;  and  this  is  not  at  all  an  uncommon  but 
a  frequent  occurrence  in  India  at  certain  seasons,  and  out- 
side and  beyond  the  so-called  endemic  area.  The  relation 
of  these  cases  to  larger  outbreaks  and  epidemics  has  not 
hitherto  been  exactly  defined,  for  when  the  epidemic  occurs 
later  on,  it  does  not  at,  all  follow   that  it  should   be  at  the 


—  46  - 

absolute  for  disapproval,  while  Koch  declares:!  "In 
these  experiments,  as  to  the  influence  of  development- 
inhibiting  materials,  the  surprising  fact  was  estab- 
lished that  comma  bacilli  extraordinarily  easily  die 
when  they  are  dried;'"  and  again — "  For  the  spread  of 
the  infective  material  the  main  condition  is,  that  the 
dejections  should  remain  in  a  moist  state,  for  as  soon 
as  they  dry  up  they  lose  their  activity y\  And  labora- 
tory experiments  and  experiences  have  demonstrated 
these  bacilli  are  among  the  most  sensitive  and  non- 
resistant  of  organisms  of  their  class,  since  a  tempera- 
ture of  either  15°  or  50°  C.  (59°  or  122°  Farh.)  is  sure 
death  thereto  within  a  z'^rjv^/'zV/ period  of  time;  more- 
over their  resistance  to  chemical  agents  is  almost  nil, 
especially  in  relation  to  acids,  hence  their  destruction 
would  be  assured  in  the  stomach  by  means  of  the 
gastric  Juice  if  the  latter  is  of  normal  reaction;  only 
in  an  alkaline  or  neutral  medium  is  it  possible  to 
secure  development.  Koch  tacitly  admits  this,  and 
Klein  and  Herman  Bigg,  and  the  whole  host  of  fol- 
lowers are  compelled   to  corroborate.      Further,  the 

same  place  or  time  or  soon  after  the  occurrence  to  which  we 
are  referred;  and  parallel  with  this  inquiry,  how  did  the 
River  Seine  become  infested  with  the  comma  bacillus,  and 
how  was  the  cause  of  the  disease  introduced  into  Hamburg, 
or,  to  take  the  latest  example,  into  the  well  at  Portel,  the 
fishing  village  near  Boulogne?" — S. 

f  Report  of  July,  1884 — "  Cholera  in  Europe  and  India," 
by  E.  O.  Shakespeare,  Washington,  1892. 

X  Italics  mine. — S. 


—  47  — 
fact  may  be  recalled  that  while  cold  in  the  main  seems 
to  inhibit  certain  epidemics  of  cholera — as  those  of 
1849  and  1866  in  certain  other  instances  it  appeared 
to  have  no  effect;  in  1830  and  1831,  in  the  height 
of  a  severe  Russian  winter,  its  ravages  were  of  a 
most  virulent  nature,  in  Moscow  with  a  temperature 
of  minus  4°  Farh.,  and  even  in  Orenburg  with  a 
temperature  of  minus  22°  Farh. 

If,  then,  the  comma  bacillus  is  the  cause,  infec- 
tion'should  be  much  more  active  at  the  bedside  than 
in  the  closet — among  physicians  and  nurses  than 
laundresses,  scavengers,  and  those  who  handle  and 
cleanse  the  dried  and  soiled  bed-clothing  and  body- 
linen, — whereas  the  precise  contrary  has  been  re- 
peatedly proven  by  the  best  of  all  tests,  practical  ex- 
perience. (Thiersch,  Niemeyer,  Tanner,  Flint,  Wat- 
son, Lebert,  et  al.)  Again,  it  is  a  well  known  fact 
cholera  dejections  may  be  boiled  to  the  utter  de- 
struction of  the  last  bacillus,  yet  be  not  deprived  of 
their  virulence;  (Virchow,  Aitken,  Lewis.) 

Arnaldo  Cantani  and  Klebs  repeatedly  obtained 
cholera  poisoning  from  sterilized  cholera  fluids,  and 
Lewis  and  D.  D.  Cunningham  as  far  back  as  1874 
made  a  like  observation.  Finally,  Jno.  Simon,  A. 
Delpech,  Wm.  Sedgwick,  Dutrieux  Bey,  Alex.  Har- 
kin,  J.  M.  Cunningham,  Lionel  Beal,  Thos.  J.  Mays, 
B.  W.  Richardson,  John  Chaine,  Mariano  Semmola — 
the  latter  recognized  as  one  of  the  most  profound 
pathologists  of   our  century — and  others,  attach    no 


-  48  - 

importance  to  microbes,  which  they  believe  at  most  to 
be  only  modified  anatomical  elements,  and  sequels 
of  the  pathology  instead  of  a  cause  thereof;  that 
they  are  accidental  accompaniments  of  disease,  of 
which  nothing  can  be  predicated  of  the  action  of  any 
particular  form;  they  are  scavengers  only. 

Thus  is  confirmed  the  trite  utterance  of  Trichum, 
d  propos  of  Koch's  bacillus,  when  he  adjured  his 
listeners  not  to  believe  the  purported  discovery  settled 
the  question  of  cholera  any  more  than  knowledge  of 
the  tubercular  bacillus  would  eradicate  pulmonary 
phthisis.  Semmola  adds:*  "  This  doctrine  at  best  is. 
based  only  on  a  hypothetical  basis;"  and,  '*  I  cannot 
comprehend  how  true  clinicians  can  accept  as  of 
practical  value  results  that  are  established  solely  in 
the  laboratory." 

Again,  the  Koch  theory  of  infection  embodies  the 
belief  that  when  a  patient  fails  to  succumb  under  an 
attack  of  cholera,  it  is  owing  to  his  organism  having 
not  only  withstood  the  onslaught  of  the  bacilli  or  the 
virulence  of  their  morbific  products,  but  that  the 
invading  hordes  must  have  perished  within  the  body. 
But  that  these  hordes  are  a  sequel  rather  than  a  cause, 
has  just  been  shown  by  Dr.  Cornet,  of  Berlin  and 
Reichenhall,  who  discovered  that  persons  apparently 
convalescent  from  the  malady  may  carry  about  with 
them  in  their  intestines,  active  living  Koch  bacilli. f 

*  Berliner  Klinische  Wochenschrift.     1891. 

f  "  The   case   in   which   this   important  discovery  was 


—  49  — 

Regarding  the  teachings  of  the  Gautier  school,  it 
may  be  said  they  have  Httle  in  common  with  pan- 
germic  and  bacterial  theorizings,  but  rest  upon  data 
positive,  precise,  easy  of  verification;  and  if  the  in- 
dications submitted  meet  with  the  attention  they  seem 
to  deserve,   a  sweeping  reformation  will  result. 

Both  Gautier  and  M.  Peter,  following  the  lead  of  the 
great  Selmi,  believe  there  are  elements  resident  with- 
in the  economy  that  may  induce  certain  specific  dis- 
eases; that  these  elements  remain  inoffensive  whilst 
elimination  and  oxydation  of  detritus  is  normally 
operative,  but  give  rise  to  disease  if  from  some  cause 
or  other  this  eUmination  and  oxydation  are  interfered 
with  whereby  the  detritus  accumulates  and  exerts  a 
toxic  influence  upon  the  nerve  centres;  in  fact,  that 
not  only  after  death,  but  even  during  life,  the  animal 
organism— in  accordance  with  physiological  and 
chemical  processes  readily  determined — has  the  power 
of   elaborating  a  numerous  class  of   alkaloids  essen- 

noticed  was  that  of  a  man  whose  mother,  wife,  and  son  died 
of  cholera.  He  himself  had  a  slight  attack,  and  was  put 
under  the  care  of  Dr.  Carl  Lauenstein,  of  the  Seemann  Hos- 
pital. He  was  nine  days  in  the  hospital,  .  .  .  recovered 
perfectly,  and  was  on  full  diet.  Last  Friday  he  was  up  and 
anxious  to  go  home,  but  was  induced  to  stay.  On  Saturday 
he  was  still  better,  and  no  motion  at  all,  and  it  was  with 
difficulty  he  was  induced  to  remain.  On  Sunday  Dr.  Cornet 
discovered  that  in  the  stools  passed  there  were  large  quan- 
tities of  comma  bacilli." — British  Medical  Journal,  Oct.  8th, 
1892. 


_  50  — 

tially  toxic  in  properties,  those  evolved  from  dead 
tissue  being  termed  pfomaines,  those  from  living  tissue 
leucomaines.^  But  this  is  not  all.  Gautier  has  also 
ascertained  that  in  the  living  animal  economy  there 
are  elaborated  azotized  uncrystallizable  salts,  sub- 
stances the  precise  character  of  which  is  still  undeter- 
mined, and  which  are  the  extractive  matters  (tox- 
albumins  ?) ;  and  while  the  ptomaines  and  leuco- 
maines  are  both  highly  poisonous,  the  extractives  are 
far  more  toxic  than  either !  This  discovery  of 
ptomaines,  leucomaines,  etc.,  though  perhaps  of  com- 
paratively little  value  from  a  therapeutic  standpoint, 
is  nevertheless  of  the  greatest  importance  to  path- 
ology. 

The  importance  of  such  authoritative  teachings 
has  not  escaped  the  germ  theorists,  who  are  forced  to 
admit  the  symptoms  that  supervene  upon  a  cholera 
attack  obviously  indicate  a  form  of  poison.  Even 
Koch,  along  with  others,  has  been  compelled  to  hesi- 


*  Ptomaine,  from  UrcSi-ia  a  "carcase"  or  dead  body, 
and  ivo,  "  material — or  in  from  Latin,  inus  "belonging  to." 
Leucomaine  from  AEvxoo/xa^  anything  whitened  as  albumen 
or  white  of  egg. 

This  nomenclature  is  far  from  satisfactory.  The  selec- 
tion of  the  term  ptomaine,  indicative  merely  of  the'conditions 
under  which  animal  alkaloids  were  first  discovered,  as  a  root 
whence  to  derive  a  name  for  these  bodies,  is  ,"too  restrictive, 
since  it  is  only  appropriate  for  alkaloids  of  post-mortem 
origin.  A  title  is  still  needed  for  alkaloids  formed  by  mor- 
bid processes  during  life — the  ptomaines  of  disease. — S, 


—  51  — 
tate,  and  to  inquire  if  some  ptomaine  is  not  a  specific 
cause,  even  while  claiming  a  microbic  origin  for  the 
disease;  and  Klein  strongly  supports  this  view.  Dr. 
A.  M.  Brown,*  who  is  vouched  for  by  Gautier  as  an 
English  exponent  of  his  ideas,  remarks: 

"Cholera,  .  .  .  monopolizing  as  it  does  so 
much  scientific  interest,  supplies  the  finest  field  for 
airing  the  respective  claims  of  the  two  pathological 
theories,  .  .  .  the  one  bacillar,  organic,  and 
strictly  biological;  the  other  toxic,  inorganic,  and 
strictly  bio-chemical.  The  first,  so  high  in  favor,  and 
with  the  entire  field  to  itself,  has  failed  egregiously  in 
its  assumed  solution.  The  various  expeditions  under- 
taken— Indian,  African,  and  European — in  bacterio- 
bacillar  interests,  have  proved  as  practically  hopeless 
and  unprofitable  as  the  discovery  of  a  north-east  pas- 
sage to  Cathay.  By  such  missions  Koch  has  only 
added  to  his  hypothetical  perplexities,  while  Klein 
and  Bouchard,  with  modified  appreciation,  preserve 
their  germ  proclivities,  and  hope  by  vested  but  truly 
humoralistic  concessions  to  solve  the  cholera  problem." 

Koch  thought  he  had  found  the  pathogermic 
entity,  but,  confronted  and  constrained  by  cold  facts, 
has  later  felt  himself  obliged  to  modify  his  positive 
utterances,  and  consequently  now  admits  the  comma 
bacillus  does  not  directly  engender  cholera,  and  that  it 


*  "  Animal    Alkaloids — The    Ptomaines    and      Leuco- 
maines."     London,  ifcSq. 


—  52  — 
can  only  do  so  indirectly  by  the  intervention  of  a 
ptomaine  which  he  supposes  it  secretes.  Thus  he 
seeks  to  ally  himself  with  the  third  class,  who  en- 
deavor to  reconcile  theory  with  fact  by  preaching  the 
"  Good  Lord,  good  Devil  "  doctrine  !  And  this  must 
imply  two  suppositions — first,  a  specific  bacillus  which 
Koch  has  not  discovered;  second,  the  secretion  of  a 
ptomaine  by  that  bacillus  which  the  Berlin  savant  and 
his  following  are  equally  as  far  from  discovering. — 
Says  Sir  Wm.  Aitken,*  d propos  of  the  foregoing: 

"  A.  G.  Pouchet  obtained  an  oily  base  belonging  to 
the  pyridin  series  from  cholera  stools,  and  Brieger  got 
from  pure  cultivations  of  the  comma  bacillus  in  beef 
broth,  in  addition  to  the  common  ptomaine  of  putre- 
faction, two  poisons  which  he  regarded  as  specific 
products  of  this  bacillus."  But  none  of  the  poisons 
which  have  been  thus  isolated  produce  exactly  the 
symptoms  of  cholera:  In  Cantani's  experiments, 
tremor,  prostration,  spasms,  and  repeated  vomiting 
were  observed;  Klebs  noticed  muscular  contractions 
and  alterations  of  the  kidney;  the  poison  obtained  by 
Pouchet  irritated  the  stomach  and  slowed  the  heart; 
one  of  L.  Brieger's  produced  muscular  tremor  and 
cramps,  while  the  other  induced  lethargy  and  feeble- 
ness of  circulation  with  occasional  bloody  diarrhoea. 
These  facts,  remarks  Aitken,  evidence  "  the  symptoms 
of  cholera  are  not  caused  by  a  poison  formed  by  the 


*"  Animal  Alkaloids."     London,  iS 


—  53  — 
action  of  the  comma  bacillus,  and  it  is  evident  that 
much  more  extended  investigation  is  required  before 
the  pathology  of  the  disease  is  accurately  understood." 
C.  H.  Fagge*  suggests  that  in  all  such  investigations 
one  must  bear  in  mind  the  possibility  of  the  poison 
being  formed,  not  in  the  intestines  merely,  but  in  the 
blood,  nerves,  and  general  tissues. 

—Thus  Koch  assumes,  Gautier  demonstrates,  and 
Klein  and  Chas.  Bouchardf  vacillaite  while  sedulously 
essaying  to  promote  fusion. 


*  "  Principles  and  Practice  of  Medicine."     London. 

f  Since  the  above  was  written,  attention  has  been  called 
to  an  editorial  in  the  Boston  Medical  and  Surgical  Journal 
for  July  28th,  1892,  from  the  pen  of  my  friend  Dr.  E.  P.  Hurd, 
of  Newburyport,   Mass.,  as  follows: 

"  The  toxic  theory  of  Bouchard,  as  set  forth  in  his  book 
'On  the  Auto-Intoxications,'  fairly  well  explains  the  symp- 
tomatology of  cholera.  He  demonstrated,  as  early  as  1884, 
by  experiments  made  with  toxic  substances  found  in  the 
stools  and  urine  of  cholera  patients,  that  the  pathogeny  of 
cholera  may  be  referred  to  multiple  intoxications. 

"  Professor  Bouchard  has  some  doubts  as  to  the  fact  of 
the  comma  bacillus  being  the  pathogenic  agent  of  cholera. 
'The  only  serious  argument,'  he  says,  'in  favor  of  Koch  s 
claim,  is  the  presence  in  the  intestines  of  cholera  patients  of 
special  micro-organisms,  which  are  not  supposed  to  be  found 
in  the  intestines  of  healthy  persons  or  of  persons  affected  with 
other  diseases.  These  micro-organisms  exist  often  in  con- 
siderable abundance,  from  the  very  first,  and  often  to  the 
exclusion  of  every  other  microbe  in  the  digestive  tube. 
Apart  from  this  empirical  ascertainment,  which  warrants 
only  a  presumption,  all  the  other  arguments  which  have 
been  alleged  are  illusory.' 

"The  toxic  alkaloids  which  Bouchard  has  extracted 
from  the  intestines  and  urine  of  cholera  patients,  greatly  ex- 


—  54  — 

ceed  those  ordinarily  contained  in  fsecal  matters.  One  of 
these,  which  forms  acicular  crystals,  seems  to  have  a  special 
virulence,  and  to  be  identical  with  the  'cholera  poison' 
which  Koch  and  Brieger  have  isolated  from  the  intestinal 
contents  of  cholera  patients,  and  which  they  believe  to  be 
generated  by  the  comma  bacillus.  There  is,  however,  no 
agreement  as  to  what  really  are  the  soluble  toxic  substances 
secreted  by  the  microbe  of  cholera.  Bouchard  affirms  that 
the  real  virus  is  eliminated  in  the  urine  in  appreciable  quan- 
tities. In  injecting  into  the  veins  of  animals  cholera  urine, 
he  has  caused  pronounced  cyanosis,  collapse,  albuminuria, 
anuria,  cramps,  and  pale,  yellowish  or  bloody  diarrhoeic 
evacuations,  like  those  which  characterize  true  cholera.  In 
injecting  the  alcoholic  extract  of  the  urine  of  cholera  patients,, 
he  has  determined  somnolence,  albuminuria,  diarrhoea,  and 
death  in  two  days. 

"  'There  is,'  says  Bouchard,  'in  cholera-urine  a  poison 
which  I  call  the  true  cholera  poison.  I  cannot  chemically 
define  it;  I  only  know  by  its  physiological  properties.  I 
know  not  if  it  is  fabricated  by  the  sick  organism  or  by 
microbes.' 

"  Bouchard's  view  then  is,  that  besides  the  primary 
infection  there  exists  in  the  pathogeny  of  cholera  a  second- 
ary intoxication,  consequent  on  the  infection.  He  thinks 
that  the  symptoms  considered  as  characteristic  of  cholera 
are  the  result  of  this  intoxication.  To  this  we  may  attribute 
the  cyanosis,  the  chilliness,  the  respiratory  troubles,  the  hic- 
cough, the  special  diarrhoea,  the  intestinal  desquamation, 
the  cramps,  the  de-hydration  of  the  blood  and  tissues,  the 
albuminuria,  the  anuria.  But  very  soon  '  there  supervenes 
a  new  source  of  systemic  intoxication  superadded  to  the 
first,  and  this  clinically  expresses  itself  by  intellectual  torpor 
—  by  somnolence,  apathy,  and  coma.  The  respiratory 
rhythm  changes,  sometimes  rising,  sometimes  falling;  it  is 
the  rhythm  of  uraemia.  The  pupils  are  contracted,  and  be- 
come punctiform.' 

"  This  is  evidently  a  different  symptom-aggregate  from 
that  of  the  initial  period,  and  is  due  to  another  kind  of 
poisoning;  in  other  words,  we  have  the  clinical  tableau  of 
uraemia  from  excess  of  disassimilation  and  blocking  of  the 
kidneys. 

"  '  In  short,  cholera  furnishes  us  an  example  of  a  double 
auto-intoxication;    one  by   an    abnormal    product, — this  the 


—  55  — 

choleriac  intoxication    properly  so  called;  the  other  by  nor- 
mal products, — constituting  a  variety  of  uraemic  poisoning.'  " 

From  the  foregoing  it  would   seem   Bouchard  is  gradu- 
ally "  undergoing  a  change  of  heart." — S. 


CHAPTER  IV. 

PATHOLOGICAL    DISCUSSION. 

Setting  theories  aside,  I  may  now  deal  with  real 
facts.  With  all  the  wrangling  of  pan-germists,  bio- 
chemical physiologists,  and  fusionists,  one  thing  is 
most  evident,  viz.  :  The  neurotic  character  of 
cholera  ! 

As  far  back  as  the  time  of  Wm.  CuUen,  who  was 
upheld  by  Sir  Thomas  Watson,  the  disease  found  place 
in  nosological  nomenclature  under  the  ^'- order  Neu- 
roses, class  Spasms."  Jules  Marey  always  considered 
the  nervous  system  as  primarily  affected  by  cholera 
poison,  and  as  determining  the  principal  phenomena 
of  the  attack,  even  the  gastro-iritestinal  symptoms. 
The  poison,  he  declares,  first  excites  the  sympathetic 
system,  whence  ensues  the  contraction  of  the  muscles 
under  the  dependence  of  that  system.  The  spasm 
of  the  arteries  of  the  greater  and  lesser  circulation, 
as  well  as  of  the  bronchial  radicles,  explains  the 
phenomena  of  the  cold  period.  In  the  period  of 
reaction,  the  arterioles  and  capillaries  relax,  aad  there 
is  stasis  of  the  circulation  and  excessive  watery  exu- 
dation. And  everything  manifestly  points  to  pro- 
found toxication  of  nerve  centres  inducing  changes 
that  are  chiefly  revealed  through  the  great  sympa- 
thetic, particularly  in  its  abdominal  and  thoracic  area. 


—  57  — 
Sir  Henry  MacCormac*  and  Chas.  Lever,f  both  of 
whom  had  extended  experience  in  Ireland  in  the 
epidemic  of  1834,  alike  regarded  the  malady  as  pro- 
voked by  a  lesion  of  the  sympathetic — a  view  sup- 
ported by  Wm.  Sedgwick,  Jas.  Johnson,  Claude 
Bernard,  D'Arsonval,  the  elder  Chermak,  Fillipo 
Picani,  D.  Cannataci,  Foster,  Guerin,  and  Alex.  Harkin. 
But  it  is  evident  we  must  look  even  further.  Mani- 
festly the  gastric  and  enteric  pathology  is  not  primary, 
but  secondary,  since  in  "  dry  cholera  "  (cholera  sicca; 
cholera  asphyxia;  cholera  siderans)  death  supervenes 
ere  there  is  any  evidence  of  intestinal  or  stomachal 
disorder  or  distress,  and  through  failure  of  the  res- 
piratory and  cardiac  centres.  Indeed,  the  latter  fac- 
tors are  so  prominent  in  every  attack  that  Drs. 
E.  A.  Parkes,  Jonathan  Hutchinson,  Geo.  Johnson, 
J.  Snow,  W.  Grissinger,  and  Surgeon-Major  J.  C. 
Hall,  were  inclined  to  believe  the  real  morbid  factor 
exists  in  the  blood  whereby  is  induced  spasm  of 
arterioles  inhibiting  pulmonary  circulation  and  pre- 
venting oxydation,  laying  especial  stress  on  the  fact 
that  there  is  likewise  evidence  of  spasmodic  contrac- 
tion of  the  circular  organic  muscular  fibres  of  the 
bronchi.     Says    Dr.    Parkes: J     "  That  there  is  some 

*"Observations  on  Spasmodic  Cholera;  Its  Origin, 
Nature  and  Treatment,"  etc.     London,  1834, 

f'Cholera  in  the  Southland  West  of  Ireland."  Dublin, 
1834. 

X  "  Researches  into  the  Pathology  and  Treatment  of 
Asiatic  or  Algid  Cholera."     London,  1847. 


-  58  - 

impediment  or  arrest  of  the  circulation  in  the  capil- 
lary system  generally,  and  in  the  pulmonary  capilla- 
ries in  particular,  appears  almost  certain;  and  it  is 
by  no  means  improbable,  from  the  whole  bearing  of 
the  facts,  that  this  is  due  to  chemical  change  in  the 
fibrin  and  in  the  mode  of  its  combination  consequent 
on  the  direct  action  of  the  active  cause." 

Evidently  the  latter  "builded  better  than  he 
knew,"  and  had  a  partial  insight  into  the  truth,  as  is 
seen  in  the  terminal  portion  of  the  above  sentence. 

Dr.  George  Johnson,  as  cited  by  Thos.  Hawkes 
Tanner,  remarks:  "During  the  state  of  collapse  the 
passage  of  the  blood  through  the  lungs  from  the  right 
to  the  left  side  of  the  heart  is  in  greater  or  less  degree 
impeded."*  But  he  differs  from  Dr.  Parkes  as  to  the 
cause  of  this  impeded  circulation,  his  hypothesis  being 
that  the  poisoned  blood  causes  contraction  of  the  mus- 
cular walls  (instead  of  spasm)  of  the  minute  pulmonary 
arteries,  the  effect  of  which  is  necessarily  to  diminish 
or  arrest  the  flow  of  blood  through  the  pulmonary- 
capillaries.  Alburtus  Eulenberg,  Chas.  Francois,  J.. 
M.  French,  and  others,  attribute  cholera-algidity  to 
cardiac  adynamia  provoked  by  nervous  irritation  pro- 
ceeding from  the  intestine,  a  theory  that  derives  sup- 
port from  the  experiments  of  Tarchonoff  and  Franck 
who  showed  that  irritation  of  the  digestive  tube  and 


*"  Notes  on  Cholera,  its  Nature  and  Treatment,"  1866 
"  The  Practice  of  Medicine."  London,   1874. 


—  59  — 

mesenteric  nerves  may  determine  more  or  less  pro- 
longed arrest  of  the  heart. 

Though  these  views  in  a  measure  clash,  they  may 
all  be  considered  as  containing  great  germs  of  fact, 
being  based  upon  observation  in  different  individuals 
under  variable  conditions;  moreover  they  are,  in  a 
measure,  reconcilable  when  later  pathological  knowl- 
edge is  brought  to  bear  thereupon,  and  due  consider- 
ation is  given  to  the  influence  of  the  nervous  system. 

Though  the  theory  of  primary  intestinal  lesion  has 
many  advocates,  who  lay  especial  stress  on  two  mani- 
fest symptoms,  viz.,  dehydration  of  blood  and  tissues, 
and  blood  poisoning — that  under  the  influence  of  the 
profuse  watery  discharges,  provoked  by  such  intes- 
tinal lesion,  the  blood  and  tissues  became  unfit  for 
nutrition  and  functional  work, — it  must  be  remembered 
that  in  many  cases  no  changes  whatever  are  to 
be  observed  after  death,  either  in  the  stomach, 
intestines,  or  elsewhere,  save  perhaps  congestion  of 
the  pulmonary  and  cutaneous  systems;  but  the  left 
heart  (as  shown  by  Simon  and  others)  is  generally 
empty,  while  the  right  is  distended  and  filled  with 
blood.  Sicluna  and  J.  M.  Bruce,*  performing  autop- 
sies on  the  victims  of  the  epidemic  that  ravaged  Malta 
in  1887,  always  observed  the  cavities  of  the  left 
heart   empty   and    of    the    right    filled    with    blood! 


*"  Treatment  of  Cholera."     Dublin  Jour.  Med.  Science. 
March,  1890. 


—  6o  — 

George  Budd*  reports  concentric  hypertrophy  in  cases 
of  sudden  death  from  cholera:  and  Jas.  Jacksonf 
especially  noticed  that  at  post-mortems  of  victims 
the  hearts  usually  exhibited  hypertrophy  of  the  left 
ventricle. 

Again,  the  elder  Flint|  lays  stress  upon  the  fact 
"epidemic  cholera  has  no  constant,  appreciable, 
anatomical  characters — none  which  appear  to  be  com- 
mensurate with  the  gravity  of  the  malady;  the 
morbid  appearances  after  death  do  not  afford  an 
adequate  explanation  of  the  symptomatic  phenomena, 
nor  do  they  elucidate  the  pathology  of  the  disease." 

Tanner  declares§  "  post-mortem  examinations 
have  thrown  little  light  .  .  ."  ;  that  "  we  naturally 
look  first  to  the  gastro-intestinal  mucous  membrane, 
but  beyond  distension  of  the  follicles  with  serum,  an 
oedematous  condition  of  the  mucous  lining,  patches 
of  venous  congestion,  and  here  and  there  rupture  of 
the  vessels  producing  ecchymoses,  we  find  nothing. 
The  blood  is  altered  more  or  less,  is  usually  of  tarry 
appearance  and  consistence,  the  proportion  of  water 
being  much  diminished,  the  fibrin  being  either  re- 
duced in  quantity  or  affected  in  character,  and  the 
corpuscles  increased,  while  the  serum  is  rich  in  albu- 
men, contains  a  slight  excess  of  urea,  and  its  salts. 


*  Medical  Chronicle,  vol.  xxi. 

f  "  Report  on  Cholera  in  France."    London,  1872. 
X  "Practice  of  Medicine."     Philadelphia,  1873. 
§"  The  Practice  of  Medicine."    London,    1874. 


—  6i  — 

collectively,  perhaps,  diminished  .  .  .  the  heart 
is  often  flaccid,  its  right  side  dilated,  the  left  side 
contracted." 

Niemeyer,  barring  those  cases  where  death  oc- 
cured  during  the  stage  of  reaction,  emphasizes  the 
fact*  "the  characteristic  changes  consist  chiefly  in 
extensive  catarrh  of  the  intestines  accompanied  by 
detachment  of  the  epithelium  and  copious  transuda- 
tion, and  in  decided  thickening  of  the  blood  and  ex- 
cessive venous  hypersemia  of  the  kidney  "  (the  latter 
mentioned  also  by  Tanner  as  an  occasional  but  by  no 
means  constant  feature). 

Lebert  remarks:f  "The  anatomical  leisons  of 
cholera  are  of  peculiar  character,  but  clearly  more  the 
consequences  than  the  cause  of  the  disease,  hence  pos- 
sess no  pathognomonic  character  whatever."  And 
again:  "The  anatomical  changes,  the  hypersemia  of 
the  mucous  membrane,  the  distension  of  the  mesen- 
teric veins  with  thick  blood,  the  ecchymoses  and 
hsemorrhagic  suffusions  of  the  mucous  membrane,  the 
swelling  and  great  softening  of  the  lymphatic  appa- 
ratus of  the  small  intestines,  are,  I  am  convinced,  not 
the  cause  of  'rice-water'  stools." 

Rudolf  von  Jaksch,  Jas.  Cagney,  Hoppe-Seyler, 
C.  Schmid,  C.  Zehnder,  Jas.  Sterling,  T.  R.  Lewis,  F. 

*Text  Book  of  Practical  Medicine,"  vol.  ii.  New  York, 
1882. 

f  "  Ziemssen's  Cyclopoedia  of  the  Practice  of  Medicine," 
vol.  i.     New  York,  1874. 


—    62    — 

Delafield,  et  al.,  corroborate  these  authors,  admit- 
ting an  inadequate  pathology  as  evinced  by  the  dis- 
ease in  any  stage;  and  when  is  further  recalled  the 
fact  there  is  no  malady  in  the  whole  nosology  that  is 
more  efficiently  assisted  in  gaining  a  foothold  in  the 
economy,  or  the  fatal  tendency  of  which  is  more 
vigorously  promoted  and  hastened  by  mental  causes, 
we  have  most  convincing  evidence  the  ultimate  source 
or  cause  of  cholera  lies  deeper  than  in  the  organs  that 
permit  of  general  review  and  inspection. 

Chas.  Bouchard  insists  "  from  the  study  of  the 
various  attempts  of  pathologists  to  explain  the  symp- 
tomatology of  cholera,  it  results  that  we  must  admit 
multiple  causes.  If  the  most  powerful  come  under 
the  head  of  intoxications,  we  must  still  make  due 
account  of  the  dehydration  of  the  blood  and  tissues, 
and  of  the  reflexes  which  take  their  start  in  the 
digestive  tube  and  affect  the  vaso-motors.  In  favor  of 
this  latter  influence,  may  we  not  refer  to  the  algidity 
and  collapses  which  sometimes  follow  the  gastric 
crises  of  tabes,  and  which  bear  so  striking  a  resem- 
bance  to  cholera  ?" 


CHAPTER  V. 

CHOLERA  CHARACTERISTICS. 

The  characteristics  of  cholera,  those  most  man- 
ifest in  its  so-called  epidemic  or  malignant  form,  and 
upon  which  differential  diagnosis  chiefly  rests,  are: 

First  Stage. — A  feeling  of  stupidity,  general 
weakness,  chilliness — more  rarely  a  regular  chill, — 
followed  by  uncontrollable  watery  diarrhoea  devoid  of 
color  or  nearly  so,  lacking  also  in  odor.  The  first 
dejections  are  apt  to  be  dark  and  pappy,  but  once 
the  contents  proper  of  the  intestines  are  cleared  out, 
they  become  of  whey-like  character,  sometimes  of 
pale  reddish  hue  owing  to  admixture  with  blood,  with 
not  the  slightest  traces  of  bile  pigment,  and  on  stand- 
ing usually  deposit  a  fine  granular,  whitish-gray  sub- 
stance which  contains  triple  phosphates,  bacteria,  fine 
shreds  of  algae  and  blood-corpuscles,  sometimes  also 
phosphate  and  crystalloid  salts  of  lime;  this  fluid  is  alka- 
line, being  disproportionately  rich  in  sodium  chloride, 
and  may  contain  some  albumen,  though  not  in  great 
quantity.  The  mvestigations  of  Surgeon-Major  Lewis 
evidence  the  flakes  and  corpuscles  of  "  rice-water  " 
stools  do  not  consist  of  epithelium,  nor  of  its  debris^ 
but  that  their  formation  "  appears  to  depend  upon  the 
effusion  of  blood  plasma;"  that  "the  bodies  found  by 
Surgeon  E.  A.  Parkes,  moreover,  correspond  very 
closely  in  their  microscopic  and  chemical  characters, 
as  well  as  in  manifestations  of  vitality,  to  the  corpus- 


-  64  - 

cles  which  are  known  to  form  in  such  fluid  and  are 
generally  to  greater  or  less  degree  associated  with 
blood-cells,  even  when  the  presence  of  such  is  not 
suspected,  especially  when  the  disease  tends  toward 
fatal  termination,  when  the  latter  have  been  frequent- 
ly seen  to  replace  the  former  altogether."*  This 
diarrhoea,  which  varies  in  frequency  in  different  epi- 
demics, may  be  regarded  as  the  warning  of  an  attack; 
and  where  it  is  absent,  patients  before  the  outbreak 
usually  feel  depressed,  tired,  and  uncomfortable.  These 
first  manifestations,  which  are  however  some  times  to- 
tally absent,  may  be  regarded  as  stadium  prodromorum. 
The  duration  of  prodromic  diarrhoea  in  cases  of 
absolute  cholera,  as  ascertained  by  Lebert,  does  not 
as  a  rule  exceed  three  days,  "but  may  continue  five 
or  even  eight  days."  He  gives  a  table  of  thirty-five 
cases,,  closely  observed  during  the  Zurich  epidemic  of 
1855,  which  is  here  reproduced: 

DURATION  OF  PRODROMIC 

DIARRHCEA.  DIED.  RECOVERED.  TOTAL. 

One  day 178 

One  to  two  days 369 

Three  days 4  5  9 

Five  days i  i  2 

Six  days 112 

Eight  days i  3  4 

Three  weeks i  . .  i 

12  23  35 

*  "  Pathological  and  Pathological  Researches."  London ^ 
18&8. 


-  65  - 

Second  Stage. — This  stage,  with  which  cholera 
not  infrequently  precipitately  commences,  constitutes 
the  attack  proper,  and  has  been  defined  as  algid  or 
asphyctic — terms  not  altogether  pertinent.  There  is 
a  feeling  of  stupidity,  general  weakness,  chilliness — 
occasionally  a  marked  rigor, — followed  by  increased 
intestinal  flux,  the  passages  being  expelled  with  great 
and  sudden  force,  without  warning;  there  appears  to 
be  complete  loss  of  power  over  the  sphincters.  In 
addition  to  the  "  rice-water  "  evacuations,  there  is 
usually  vomiting — which  in  many  cases  is  a  prom- 
inent and  persistent  symptom, — the  expelled  matters, 
like  those  from  the  intestine,  being  devoid  of  color 
and  odor;  this  emesis  may  appear  as  a  much  more  ter- 
rible symptom  than  the  diarrhoea.  A  notable  fact  is, 
absence  of  pain,  whereby  the  sufferer  is  enabled  to 
endure  the  attack  with  comparative  indifference  up  to 
the  actual  occurrence  of  cramps. 

The  cramps — in  the  lower  extremities  and  abdo- 
men, perhaps  across  loins,  rendering  the  muscles  as 
"hard  as  wood  "  or  "  drawing  into  knots,"  as  it  were, 
the  frequency  of  which  varies  indifferent  epidemics, 
—  constitute  one  of  the  most  remarkable  symptoms  of 
the  malady.  Lebert  usually  observed  in  the  second 
half  of  the  attack  proper,  rarely  earlier,  and  that  they 
always  assumed  a  tonic  character  in  adults,  while 
in  children  the  tetanic  form  commonly  obtained;  oc- 
casionally, though  rarely,  the  muscles  of  the  face  are 
involved.     Each  attack  lasts  but  a  few  minutes,  but 


—   66  — 

the  frequent  recurrence  and  excruciating  character 
mark  as  the  most  distressing  manifestation  of  the  dis- 
ease. Sometimes  cramps  persist  to  the  very  end  in 
rapidly  fatal  cases,  but  usually  they  cease  with  the 
progress  of  the  asphyxia,  and  in  more  protracted, 
cases,  in  the  cold  period  just  preceding  reaction.  In 
a  few  instances  both  cramps  and  vomiting  are  ob- 
served together  at  the  very  outset  of  the  malady,  in 
conjunction  with  dizziness,  headache,  very  great  dis- 
quiet and  anxiety — though,  as  a  matter  of  fact,  most 
patients  exhibit  a  certain  indifference.  At  the  height 
of  a  very  intense  epidemic  are  sometimes  seen  pa- 
tients who  rapidly  collapse  with  symptoms  of  great 
distress,  becoming  cold,  cyanotic,  dying  after  one,  two 
three,  five,  six  or  more  hours;  but  in  such  there  is 
usually  an  abundance  of  colorless  transudation  into 
the  intestine. 

In  the  most  intense  or  malignant  development  of 
the  malady,  persons  may  die  pulseless,  cold,  cya- 
nosed,  etc.,  with  no  evidences  of  vomiting  or  diar- 
rhoea, and  with  positively  no  characteristic  changes  to 
be  found  in  the  intestines  or  elsewhere,  and  no  tan- 
gible cause  for  fatality;  but  these  cases  are  so  rare 
of  late  years  that  a  large  number  of  medical  men  are 
inclined  to  deny  the  existence  of  "  dry  cholera,"  which 
was  generally  considered  as  proved  in  the  earlier  epi- 
demics. 

Thirst  is  invariably  a  most  assertive  symptom, 
and    usually  very  urgent,    though  its  degree   is   apt 


-  67  - 

to  be  in  inverse  proportion  to  the  severity  of  the 
seizure;  patients  clutch  at  the  attendants'  hands  as 
the  glass  or  cup  is  held  to  them,  in  terror  lest  it 
should  be  taken  away  too  soon.* 

The  circulation  is  greatly  diminished,  the  pulse 
frequent  and  proportionately  weakened,  ranging  from 
t2o  to  140  per  minute,  though  under  some  circum- 
stances it  becomes  more  and  more  feeble  without 
acceleration,  and  in  more  pronounced  or  asphyctic 
conditions  may  fall  below  normal.  When  the  state  of 
collapse  is  fully  developed  the  pulse  is  extinct  at  the 
wrist;  next  the  pulsation  in  the  carotids  disappears; 
finally  there  is  feebleness  or  absence  of  the  apex  beat 
of  the  heart,  and  of  all  cardiac  sounds,  evidencing 
greatly  diminished  power  of  the  central  organ  of  cir- 
culation. There  is  also  general  venous  stasis  giving 
rise  to  remarkable  lividity  or  blueness  at  the  roots  of 


*Says  a  correspondent  of  the  British  Medical  Journal,  a 
volunteer  nurse  of  the  Eppindorf  hospital,  writing  from 
Hamburg  recently: 

"  There  are  two  pretty  yellow-haired  sisters  who  lie  in  a 
cot,  with  whom  the  characteristic  ravenous  thirst  is  the  most 
pronounced  symptom.  They  have  no  vomiting  and  but  little 
diarrhoea.  They  sleep  about  twenty-three  hours  out  of  the 
twenty-four,  and  in  their  lethargy  thirst  seems  to  be  the 
only  consciousness.  One  lies  grasping  a  cup  with  both  her 
small  hands,  and  if  an  attempt  be  made  to  take  it  from  her, 
she  automatically  and  drowsily  opens  her  mouth  for  a 
draught,  not  knowing  when  the  milk  is  given  her,  but 
swallowing  mechanically." 


—  68  — 

the  nails,  in  the  lips,  face,  and  on  the  surface  of  the 
body  generally;  icy  coldness  of  the  skin  everywhere  — 
of  the  nose,  tongue,  and  even  the  breath;  frequently 
noises  in  the  ears  or  head,  dizziness,  dimness  of  vision, 
deafness.  The  skin  becomes  shrivelled,  and  if  picked 
up  in  a  fold  remains  puckered  for  a  time,  retracting 
but  slowly.  Finally  the  entire  surface  of  the  body  is 
bedewed  with  death-like  dampness. 

The  number  of  respirations  is  usually  increased, 
often  to  twenty-four,  thirty,  or  even  forty  per  minute, 
at  the  same  time  short,  confined,  and  imperfect,  fre- 
quently of  sighing  or  irregular  rhythm;  the  expired 
atmosphere,  when  collapse  is  complete,  besides  being 
of  low  temperature,  contains  more  oxygen  and  less 
carbonic  acid  than  in  health,  evidencing  notable  de- 
ficiency in  the  changes  incident  to  the  function. 
There  is  also  marked  alteration  of  the  voice  (vox 
cholericd),  which  becomes  whispering  and  unnatural 
owing  to  diminished  volume  of  respiratory  gases; 
oppression  and  pain  at  the  praecordia  are  manifest, 
often  of  such  excruciating  nature  as  not  to  be  ac- 
counted for  solely  by  the  dyspnoea  present. — In  many 
instances  this  dyspnoea  is  more  particularly  marked 
during  the  period  of  violent  discharges  from  stomach 
and  intestines  and  at  the  beginning  of  the  absolute 
algid  stage,  only  to  disappear  again  with  the  conclu- 
sion of  this  period;  pressure  over  the  stomach  usually 
aggravates.  Cough  is  scarcely  ever  observed;  and 
stertor  is  but  exceptionally  noticed  and  only  in  fatal 


-  69  - 

cases.  In  many  instances  complete  aphonia  super- 
venes, the  motion  of  the  lips  being  seen  during  efforts 
at  articulation  alone;  and  though  this  condition  may 
at  times  yield  for  a  brief  moment,  it  is  usually  only 
when  the  intensity  of  the  spasmodic  muscular  con- 
tractions causes  the  patient  to  cry  out. 

Nothing  is  more  constant  in  this  stage  than  the 
participation  of  the  kidneys,  and  the  manifold  effects 
resulting  therefrom.  Albuminuria  may  sometimes 
supervene,  the  cloudiness  varying  from  light  opales- 
cence to  abundant  deposit  on  ebullition,  followed  by 
partial  or  complete  suppression  of  the  renal  secretion. 
Usually  the  microscope  reveals  a  large  number  of 
wavy  casts,  most  manifest  when  the  urine  has  not 
been  clouded  by  heating;  also  uric  acid  salts,  as  well 
as  some  blood  corpuscles;  and  test  with  muriatic  acid 
is  apt  to  exhibit  a  large  amount  of  indigo  pigment 
(indican)  which  is  certainly  suggestive  of  profound 
disturbance  of  nerve  centres,  and  also  of  the  close  re- 
lationship of  the  disease  to  malarial  disorders.  Lebert 
shows,  in  his  report  on  the  Zurich  epidemic  of  1855, 
that  discoloration  and  commencing  fatty  degenera- 
tion may  be  recognized  in  the  cortical  substance  of 
the  kidneys  of  individuals  who  have  died  early  in  the 
asphyctic  stage,  and  that  this  degenerative  parenchy- 
matous nephritis,  which  is  more  distinctly  anatomical 
the  longer  it  lasts,  is  not  sufficient  to  explain  the 
anuria  that  supervenes;  further,  it  must  be  noted  that 
the  nephritis  of  cholera  depends  for  its  origin  upon 


—  70  — 

disturbance  in  the  nerve-centres,  since  it  never  by  any 
accident  becomes  chronic,  but  disappears  with  the  final 
vestiges  of  the  disease.  Lebert  adds:  "  In  all  the  four 
years  after  the  epidemic  in  Zurich,  I  never  was  called 
upon  to  treat  one  of  my  patients  for  chronic  nephritis, 
and  among  a  great  number  of  nephritic  patients  in 
Basel,  I  never  found  one  in  whom  the  nephritis  could 
in  any  way  be  referred  to  a  past  attack  of  cholera." 

It  should  be  remarked  that  all  the  foregoing 
symptoms  are  apt  to  follow  each  other  much  more 
rapidly  in  children,  especially  under  three  years  of 
age,  than  in  adults,  and  death  usually  terminates  with 
convulsions;  all,  however,  may  exhibit  different  com- 
binations .  in  different  degrees  of  intensity,  and  so 
establish  from  the  start  the  distinction  between 
lighter  and  graver  forms  as  well  as  between  the  nu- 
merous transitional  grades.  As  a  rule  patients  really 
suffer  but  a  very  few  hours,  and  then,  as  already 
noted,  only  in  consequence  of  cramps,  since  the 
intestinal  and  stomachal  discharges  are  painless,  be- 
tween which  profound  rest  occurs  that  closely  bor- 
ders on  apathy.  The  expression  of  the  face,  in  the 
beginning  may  manifest  exhaustion  and  discomfort, 
but  such  is  speedily  followed  by  apparent  indiffer- 
ence; later  the  sunken  eyes,  which  are  peculiar  to 
grave  cases,  become  remarkably  dull  and  dry,  and 
are  only  imperfectly  covered  by  the  lids. 

The  diarrhoeal  discharges  may  vary  from  three 
to  twenty,  but   seldom    exceed   ten    or   twelve,  each 


—  71  — 
amounting  to  perhaps  four  or  six  ounces,  so  that  on 
the  average  the  material  transuded  from  the  intes- 
tines does  not  exceed  three  or  five  pints;  the  quantity 
lost  by  emesis  is  perhaps  much  less;  further,  in  either 
case  the  amount  of  fluid  lost  is  not  more  copious  in 
fatal  seizures  than  in  those  which  recover.  The  ease 
with  which  the  contents  of  the  stomach  are  expelled 
is  most  remarkable,  since  the  act  partakes  of  the 
character  of  simple  regurgitation,  occurring  in  series 
of  efforts,  repeated  three,  four,  eight,  ten,  or  more 
times.  The  whole  period  of  all  discharges  varies  be- 
tween eight  and  twenty-four  hours;  they  then  become 
m-ore  and  more  infrequent,  finally  wholly  cease  for 
several  hours,  perhaps  for  a  day  or  two,  only  to 
return,  perhaps,  at  irregular  periods;  vomiting  is 
especially  apt  to  return  after  the  ingestion  of  fluids. 
The  absence  of  bile  pigment  in  the  stools  seldom 
lasts  more  than  twenty-four  hours,  when  the  period  of 
reaction  (third  stage)  sets  in  and  they  become  yellow- 
ish-green; but  before  they  wholly  return  to  normal, 
there  is  an  irregular  exhibition  of  faecal  material 
varying  between  moderate  diarrhoea  and  constipation, 
unless  dysentery  complicates. 

There  is  entire  absence  of  fever  or  febrile  con- 
dition. The  temperature  is  depressed,  the  thermom- 
eter falling  to  93°  and  to  90°  Farh.— rarely  below 
the  latter  figure,  though  it  has  been  known  to  reach 
.  75°  Farh., — notwithstanding  which  the  sufferer  com- 
plains of   oppression   and  prefers   to   lie    uncovered; 


—  72  — 

generally  during  both  collapse  and  reaction,  the  tem- 
perature in  vagina  or  rectum  (or  both)  is  three  or 
four  degrees  higher  than  in  the  axilla,  which  in  turn 
is  at  least  one  or  two  degrees  lower  than  in  the 
mouth. 

Malignant  (asphyctic)  cholera,  runs  a  very  acute 
course,  and  patients  may  die  at  any  time  in  from  two 
to  twelve,  eighteen,  or  twenty  hours;  death,  however,  is 
comparatively  rare  in  the  first  twelve  hours,  occuring 
usually  in  the  succeeding  ten  or  sixteen,  and  when  oc- 
curring on  the  second  day  is  usually  in  consequence  of 
imperfect  reaction.  The  algid  stage  rarely  lasts  longer 
than  two  days,  and  the  evacuations  often  cease  some 
time  before  dissolution,  though  this  is  very  far  from  be- 
ing a  favorable  sign,  since  it  is  due,  not  to  cessation  of 
transudation,  but  to  complete  paralysis  of  intestinal 
muscles;  per  contra,  patients  in  whom  the  evacuations 
continue  for  a  long  time,  recover  more  frequently  than 
those  in  whom  the)'^  cease  suddenly;  consequently  the 
occurrence  of  intestinal  paralysis  must  be  regarded  as 
a  most  unfavorable  manifestation,  while,  on  the  other 
hand,  persistence  of  evacuations  evidences  such  par- 
alysis has  not  supervened,  hence  justifies  more  favor- 
able prognosis. 

Niemeyer  early  advanced  the  opinion  that  temper- 
ature diminishes  only  at  the  periphery  of  the  body  re- 
maining elevated  within,  an  assumption  now  generally 
accepted  by  the  medical  world.  Through  numerous 
careful  observations  of  the  temperature  of  cholera  pa:- 


—  73  — 
tients  in  the  algid  stage,  Jiiterborgk  arrived  at   the 
following  conclusions: 

"  The  head,  extremities,  etc.,  are  colder  than  in 
almost  any  other  disease: 

"The  temperature  of  the  cavities  of  the  body,  such 
as  the  vagina  and  rectum,  is  the  highest  (that  can  be 
measured)  in  the  body,  and  should  always  be  taken 
for  measurements: 

"  Whether  the  case  be  favorable  or  fatal,  the  tem- 
perature within  the  body  is  usually  increased,  rarely 
normal,  and  more  rarely  diminished,  although  no 
cause  for  this  has  ever  been  found  in  the  pathological 
symptoms  during  life  or  on  autopsy — [Another  evi- 
dence of  the  neurotic  character  of  the  disease. — S.]: 

"  The  temperature  of  the  whole  body  usually  rises 
with  the  approach  of  death;  but  there  are  cases  where 
this  rise  takes  place  without  one  being  able  to  find 
any  reason  for  this  deviation:" 

Again:  ''The  commencement  of  reaction  is  not 
accompanied  by  any  elevation  of  temperature,  but  the 
interior  of  the  body  usually  cools  off,  while  the  outer 
parts  warm  up: 

"  In  cases  of  protracted  reaction,  the  temperature 
of  the  whole  body  generally  sinks  below  the  normal: 

"  The  inflammatory  sequelae  usually,  if  not  always, 
excite  decided  elevation  of  temperature: 

"  During  perfect  convalescence,  an  abnormal 
elevation  of  temperature  is  often  seen  without  any 
pathological  cause  therefor  being  discoverable." 


—  74  — 
An  abnormal  and  notable  condition  of  the  nervous 
system,  is  manifest  from  the  fact  that,  while  the  intel- 
lect remains  clear  to  the  last*— and  though  the  sufferer 
is  sometimes  quite  hopeful, — there  is  in  general  an 
apathetic  condition  frequently  amounting  to  com- 
plete callousness;  there  are  no  apprehensions,  and 
little  care  as  to  what  the  ultimate  result  may  be, 
though  perhaps  prior  to  the  seizure  there  may  have 
been  intense  dread  of  the  disease. — The  terrible 
clearness  of  mind  and  recognition  of  the  end  which 
is  said  to  have  characterized  the  earlier  epidemics, 
has  not  been  witnessed  during  the  present  rav- 
ages of  the  disease  in  Europe.  In  some  cases 
there  is  great  restlessness  and  tossing — unconscious 
movements  to-and-fro, — though  often  the  sufferer  is 
quiet,  and  appears  to  experience  no  inconvenience  save 
when  disturbed  by  the  evacuations,  vomitings,  or 
cramps.      Delirium    is   generally   absent,   but   occurs 


*"  It  is  remarkable,  notwithstanding  the  great  debility 
which  makes  every  motion  difficult,  and  the  profound  pros- 
tration that  is  expressed  in  every  feature,"  says  Lebert, 
"  that  the  patients  not  infrequently  possess  entire  conscious- 
ness. This,  to  me,  was  one  of  the  most  disagreeable  im- 
pressions of  the  Paris  epidemic — to  hear  sufferers  in  whom 
the  pulse  was  no  longer  perceptible,  in  whom  the  face  was 
cyanosed  and  cold,  still  speaking  with  the  most  perfect 
possession  of  all  the  faculties  of  the  mind."  According  to 
Reinhardt  and  Leubuscher,  some  insane  patients  entirely 
recover  sanity  for  the  time  being,  though  the  sanity  vanishes- 
with  convalescence;  others  remain  insane  to  the  end. — S. 


—  75  — 
more  frequently  among  alcoholics,  and  later  in  the 
typhoid  state  (third  stage)  during  which  it  alternates 
with  sopor;  in  cases  of  pronounced  ursemia,  it  is  some- 
times attended  with  convulsions.  Strange  to  say, 
muscular  strength,  real  or  apparent,  appears  to  persist 
in  most  extraordinary  degree  to  the  very  last,  and  pa- 
tients if  not  prevented  will  frequently  get  up  and  walk 
about  a  few  moments  before  dissolution.  Again,  **walk- 
ing  cholera"  is  by  no  means  uncommon,  the  sufferers 
keeping  their  feet  until  fairly  in  the  throes  of  death,  and 
in  such  cases  locomotion  appears  to  hasten  fatality. 

Death  is  usually  peaceful,  by  asthenia  and,  as 
already  noted,  may  take  place  at  any  time  from  two 
to  twenty-four  hours  after  the  attack — it  is  a  gradual 
"going  out,"  the  "  rattling  of  the  throat  "  which  per- 
tains to  most  diseases,  being  conspicuous  only  by  its 
absence;  or  if  surviving  beyond  twenty-four  hours, 
there  is  usually  manifest  evidence  of  amendment. 
Commonly  patients  become  lethargic,  the  lethargy  cul- 
minating in  sleep;  sleep  in  turn  is  merged  into  coma, 
and  coma  into  dissolution.  As  in  many  other  severe 
diseases,  there  is  usually  observed  an  elevation  of 
temperature  as  the  fatal  end  approaches,  while  the 
exhalation  of  carbonic  acid  gas  is  very  much  dimin- 
ished; the  temperature  continues  to  rise,  in  many 
instances  even  after  death,  as  Davey  observed  as  long 
ago  as  1839 — an  observation  that  has  since  been  con- 
firmed in  a  series  of  other  satisfactory  tests.  The 
bodies  cool  off  very  slowly. 


-  76  - 

Regarding  the  mortality  of  cholera,  it  may  be 
remarked  no  one  has  ever  been  able  to  complete  sta- 
tistics of  the  graver  cases,  because  the  lighter  ones 
for  the  most  part  escape  accurate  observation,  while 
as  to  the  more  serious  the  mortality  varies  (according 
to  the  most  conscientious  statements),  between  two- 
fifths  and  three-fifths  (the  average  may  be  put  at 
one-half),  though  in  some  local  epidemics  under 
unfavorable  circumstances,  especially  in  asylums  for 
the  aged  and  for  incurables,  it  reaches  as  high  as 
two-thirds,  or  even  three-fourths.  Nearly  one-third 
of  the  deaths  occur  within  twenty-four  hours,  and 
about  one-half  of  all  the  deaths  occur  in  the  first 
two  days.  In  the  neighborhood  of  one-sixth  die  on 
the  third  day  in  consequence  of  imperfect  reaction, 
and  about  one-third  during  protracted  convalescence 
and  in  the  typhoid  state — after  from  four  to  twelve 
days.  In  favorable  cases  of  confirmed  cholera,  and 
in  half  of  all  cases  that  recover,  convalesence  occurs 
in  three  or  four  days;  in  the  other  half  which  re- 
cover, it  occurs  irregularly  up  to  the  second  half  of| 
the  first  week.  From  the  beginning  of  convalescence 
to  perfect  recovery,  a  period  of  from  three  to  eight 
days  usually  intervenes,  varying  according  to  the 
character  of  the  attack,  and  the  characteristics  of  the 
individual  patient  and  his  surroundings. 


CHAPTER  VI. 

REACTION  AND  CONVALESCENCE. 

Third  Stage. — Although  in  the  preceding  stage 
all  symptoms  may  reach  such  intensity  that  a  large 
number  of  those  seized  cannot  survive,  yet  in  other 
numbers  a  third  or  so-called  "stage  of  reaction" 
supervenes,  which  exhibits  most  remarkable  tendency 
to  restoration  of  physiological  function,  though  cer- 
tainly not  always  with  equal  results;  it  is  possible 
(though  rarely  witnessed),  for  recovery  to  be  most 
rapid. 

The  first  improvement  is  manifested  by  some 
repression  of  the  discharges;  even  though  emesis  and 
diarrhoea  are  still  persistent,  the  quantity  is  dimin- 
ished and  the  whey-like  character  lost;  in  some  in- 
stances, thus  early,  repression  may  be  complete,  even 
to  a  degree  constituting  absolute  constipation.  An- 
other evidence  of  improvement  is  when  the  stomach 
fails  to  reject  the  fluids  ingested,  whereby  assurance  is 
had  that  the  function  of  absorption  is  no  longer 
in  abeyance,  and  restoration  of  the  fluids  of  the 
circulation,  lost  by  transudation,  possible.  The 
capillary  circulation  is  first  renewed.  Next  that  con- 
trolled by  the  carotids.  Then  the  radial  pulse  (which 
before  could  not  be  felt  or  was  scarcely  perceptible) 
quickly  regains  its  strength,  and  in  a  few  hours  is 
often  stronger  and    fuller   than  in  the  normal   condi- 


—  78  - 

tion;  usually,  also  it  is  rapid,  though  seldom  increased 
above  ninety  or  one  hundred,  perhaps  with  distinct  dic- 
rotic beat.  The  double  heart  tones  also  soon  become 
normal  and  regular,  the  blowing  sound  synchronus 
with  the  diastole,  disappearing.  Should  venesection 
now  be  attempted,  the  blood  will  be  found  to  flow 
almost  as  freely  as  in  health,  though  of  course,  the 
proportion  of  serum  is  greatly  diminished.  As  soon, 
too,  as  circulation  is  restored,  the  cyanosis  disappears, 
though  many  patients  preserve  for  some  time  a 
marble  or  cadaverous  appearance.  Heat  gradually 
diffuses  hself  into  the  peripheric  parts  of  the  body,  in 
fact  often  transcends  a  normal  medium  temperature; 
and  possibly  profuse  perspiration  may  be  induced, 
either  of  spontaneous  character,  or  as  the  result  of 
hot  drinks;  when  temperature  exceeds  the  normal, 
and  the  cheeks  become  suffused  with  dark  red,  the 
eyes  also  injected,  lachrymose,  and  painful,  and  gen- 
eral evidences  of  fluxionary  cerebral  and  other 
organic  hyperaemia,  a  clinical  picture  is  presented 
that  oftentimes  is  most  difficult  to  interpret;  it 
sometimes  disappears  spontaneously,  and  again  is 
evidence  of  imperfect  reaction  and  threatening  se- 
quelae. Such  congestions  are  more  frequent,  violent, 
and  dangerous  in  children;  indeed,  the  stage  of  re- 
action is,  in  the  main,  more  intense  in  the  little  folk, 
though  of  shorter  duration,  and  demands  watchful 
care.  Even  most  adults  complain  of  a  feeling  of  cold 
and  heaviness  in  and   about  the  head,  more  manifest 


—  79  — 
about  the  occiput  or  sinciput;  roaring  of  the  ears  or 
tintinabulations  are  common;  and  notwithstanding  a 
certain  tendency  to  somnolence,  those  persons  most 
enfeebled  are  usually  sleepless. 

Cramps  cease,  as  a  rule,  with  the  beginning  of 
reaction;  but  the  urine  remains  scanty,  or  altogether 
suppressed,  for  twenty-four  or  more  hours,  and 
always  exhibits  traces  of  albumen  as  soon  as  passed, 
which  traces  persist  for  from  two  to  seven  days.*  Res- 
piration is  normal;  dyspnoea  absent  or  nearly  so,  having 
been  markedly  lessened  toward  the  conclusion  of  the 
second  stage.  When  the  convalesence  is  rapid,  the 
tongue  clears  off,  the  bad  taste  is  lost,  appetite  re- 
turns, sometimes  to  a  degree  that  causes  error  in  diet 
and  consequent  relapse.  The  discharges  from  the 
intestines    may    persist,    but   soon     assume    a    more 

*In  observations  at  Zurich,  Lebert  found  the  first  urine 
after  total  suppression,  was  not  passed  until  forty-eight 
hours  after  the  beginning  of  the  disease.  As  a  rule  it  was 
regarded  the  secretion  would  be  restored  in  the  course  of  the 
third  or  in  the  beginning  of  the  fourth  day.  "The  first  urine 
passed  was,  usually,  small  in  quantity,  in  two  cases  bloody, 
and  once  attended  with  violent  pains  about  the  kidneys. 
Several  hours,  from  eight  to  twelve,  usually  elapsed  between 
this  first  and  the  second  discharge.  Specific  gravity  varied 
between  1.007  and  i.oio.  At  first  there  was  considerable 
brown  coloring  matter  present,  and  on  boiling  with  nitric 
acid  it  aften  showed  a  light  bluish  tint  (indigo  coloring  mat- 
ter). Only  once  was  the  first  urine  somewhat  cloudy,  with- 
out albumen;  in   all   other  cases    albumen  was  present,  and 


—  8o  — 

natural  color  and  solid  consistence;  the  casts  and 
albumen  disappear,  and  progress  toward  health  is 
rapid,  so  that  the  latter,  barring  accidents  and  slight 
after-pains,  may  be  regarded  as  established  in  from 
ten  to  fourteen  days  subsequent  to  the  primary 
seizure.  Says  Lebert,  "  If  nearly  half  the  patients 
die  in  the  algid  stage,  in  more  than  half  of  the  rest, 
the  stage  of  reaction  goes  on  to  favorable  termina- 
tion." In  women,  metrorrhagias,  during  or  in  the 
intervals  of  menstruation,  are  not  infrequent  during 
reaction  and  convalescence. 

At  all  periods  of  life,  especially  in  advanced  age, 
reaction  may  be  imperfect,  may  even  be  followed  by 
a  relapse  to  the  second  stage;  yet  many  cases  recover 
in  spite  of  numerous  vicissitudes  and  fluctuations:  Or 
the  diarrhoea  and  vomiting  may  recur  from  time  to 
time  with  critical  symptoms;  or  a  dysentery  may  alter- 


remained  for  three  or  four  days  and  sometimes  longer;  the 
quantity  of  albumen  varied,  and  when  it  disappeared  the 
quantity  of  urine  became  much  more  copious." 

According  to  investigations  of  Lehmann  and  Volk, 
confirmed  by  Prof  Buhl,  of  Munich,  the  first  urine  voided  is 
only  quantitatively  small  and  albuminous,  but  contains 
traces  of  sugar,  a  little  sodium  chloride,  and  relatively  very 
little  urea;  but  in  the  two  succeeding  days  the  quantity  of 
urine,  as  well  as  its  relative  proportions  of  urea  and  salt, 
greatly  increases,  even  far  exceeds  the  normal,  and  then, 
after  some  variation,  again  returns  to  the  natural  condition, 
when  the  albumen,  casts,  and  abnormal  pigment  disappear, 
and   the  specific  gravity  becomes  normal. — S. 


nate  with  obstinate  constipation,  the  former  green  or 
greenish  yellow  and  gelatinous;  the  tongue  does  not 
clear  up;  anorexia,  bad  taste  in  mouth,  and  thirst, 
continue  to  torture;  the  little  nourishment  taken  is 
either  speedily  rejected  or  induces  profound  distress. 

Catarrhal  inflammation  of  the  genito-urinary 
tract  is  especially  apt  to  delay  convalescence,  and 
often  in  conjunction  with,  or  succeeded  by,  a  diphthe- 
ritic condition  of  the  prima  vioe  induced  by  irritation 
of  the  denuded  intestines  or  their  contents.  Most 
patients  who  fall  into  this  state  die  of  exhaustion. 

Pneumonia,  or  so-called  typhoid  pneumonia,  is 
especially  apt  to  supervene;  and  Niemeyer  remarks 
that  "in  old,  decrepit  persons,  if  physical  examina- 
tion be  neglected,  the  outward  resemblance  and  the 
subjective  symptoms  often  cause  pneumonia  to  be 
diagnosed  as  catarrhal  fever,  nervous  influenza, 
typhus,  etc."  According  to  his  experience,  acute 
croupous  nephritis,  with  the  retention  of  urine  it  causes 
by  plugging  of  the  uriniferous  tubules,  is  a  common 
sequel  of  cholera  asphyxia,  but  by  no  means  the  con- 
stant cause  of  cholera  typhoid,  as  has  often  been 
asserted. 

"  If  the  secretion  of  urine  remains  suppressed 
after  the  disappearance  of  the  symptoms  of  collapse, 
or  if  the  scanty  urine  contains  quantities  of  albumen 
and  fibrinous  casts  for  days;  if  vomiting  recommences 
and  the  patients  complain  of  severe  headache  and 
become  comatose,  or  have  epileptiform  convulsions; 

6    KKK 


—    82    — 

it  is  safe  to  make  a  diagnosis  of  acute  croupous 
nephritis  with  so-called  ursemic  intoxication;  in  such 
cases  the  skin  has  occasionally  been  found  encrusted 
with  crystallized  urea."     (Niemeyer.) 

If  the  first  or  second  day  after  the  cessation  of 
the  asphyctic  symptoms  the  patients  do  not  pass  a 
normal  or  at  least  large  amount  of  urine,  or  the 
albumen,  at  first  very  constant,  does  not  disappear 
after  a  few  days,  they  are  apt  to  fall  into  a  state  of 
exceeding  apathy  and  stupor,  or  muttering  delirium, 
when  the  tongue  becomes  dry  and  crusted,  the  pulse 
frequent  and  often  double,  the  temperature  elevated, 
and  they  slip  down  toward  the  foot  of  the  bed;  indeed 
the  condition  so  exactly  resembles  severe  enteric  fever 
as  to  fully  warrant  the  title  of  cholera  typhoid.  Be- 
sides, there  is  usually  a  foetid  diarrhoea  in  which  are 
discovered  shreds  of  epithelium;  and  while  the  pa- 
tients can  scarcely  be  aroused  from  the  comatose 
state,  they  twitch  the  face,  or  recover  consciousness 
and  complain  of  pain,  if  strong  pressure  is  made  upon 
the  abdomen.* 

If  there  is  catarrhal  or  diphtheritic  inflammation 
of  the  intestine,  or  of  the  genito-urinary  tract,  a  pneu- 
monia, a  pleurisy,  or  other  of  the  inflammatory  sequelae 
of  cholera,  the  appearance  of  the  patient  does  not 
materially  differ   from  the   above   description.     The 


*  So  called  cholera  typhoid  is  one  of  the  most  common 
forms  of  protracted  convalescence,  and  considered  by  Fre- 
richs  as  a  uraemic  condition  purely. — S. 


-  83  - 

typhoid  peculiarities  prevail  in  completeness,  while  the 
symptoms  of  the  origmal  or  local  disease  become  sub- 
jective, falling  into  the  background  or  disappearing  en- 
tirely. Finally,  in  many  cases,  neither  during  life  nor 
on  autopsy,  is  it  possible  to  discover  any  local  lesions 
to  which  can  consistently  be  referred  the  exhausting 
fever,  of  which  so  many  die  after  the  cholera  proper 
has  run  its  course — further  evidence  of  nerve-toxaemia. 

Particular  importance  has  been  attached  by  some 
to  the  fact  that  during  the  so-called  cholera  typhoid 
a  maculated,  papular,  erythematous  exanthema  has 
been  observed,  that  may  appear  of  decided  urticarial 
character,  or  show  a  roseola-like  appearance;  it  differs 
from  the  eruption  of  typhus  in  that  it  begins  at  the 
toes  and  spreads  up  to  the  trunk,  where  it  is  most  man- 
ifest, becoming  very  imperfect  on  the  face  and  head; 
the  spots  and  papules  may  also  run  together  and  form 
a  diffuse  redness  in  different  places — very  much  as  is 
seen  in  certain  forms  of  malaria.  This  eruption 
seldom  manifests  itself  before  the  end  of  the  first,  and 
often  not  until  during  the  second  week,  and  notably 
most  of  the  patients  thus  affected  recover;  it  is  not, 
however,  so  constant  a  symptom  of  cholera  typhoid  as 
to  be  pathognomonic,  and  is  more  apt  to  occur,  per- 
haps, where  sinapisms  have  been  repeatedly  or  con- 
tinuously applied  to  the  extremities  during  the  algid 
stage,  or   massage  has  been  energetically  used. 

Sleeplessness,  a  condition  of  suUenness,  etc.,  some- 
times supervenes  during  apparent  convalescence,  when 


—  84  - 

the  patients  may  either  fall  back  into  the  condition  of 
asphyxia,  or  continue  to  improve;  but  the  latter  is 
usually  at  the  expense  of  numerous  suppurations^ 
manifested  as  a  crop  of  boils,  perhaps  as  abscesses  of 
the  parotid  or  of  the  larynx,  or  by  general  pyaemia. 

It  is  needless  to  remark  that  this  third  stage  is 
one  of  danger  accordingly  as  it  manifests  in  greater 
or  less  degree  the  pneumonic  or  typhic  condition, 
though  in  any  event  it  is  apt  to  induce  general  im- 
pairment of  the  system  that  persists  for  a  long 
period. 

Of  the  anatomical  changes  that  take  place  during 
or  supervene  upon  a  cholera  attack,  it  is  impossible  to 
speak  in  complete  detail.  However,  the  great  with- 
drawal of  serum  from  the  blood  enables  the  bodies  of 
those  deceased  to  resist  decomposition  to  a  remark- 
able degree,  hence  the  changes  usually  encountered 
post-mortem  are  lacking.  It  has  before  been  re- 
marked that  the  corpses  are  greatly  shrunken,  of 
dusky  or  livid  color;  that  rigor  mortis  is  rapidly  de- 
veloped and  persists  for  an  unusual  length  of  time; 
and  that  very  remarkable  and  violent  contractions  of 
the  muscles  are  by  no  means  uncommon,  so  much  sa 
as  to  give  rise  to  weird  tales  of  unfortunates  buried 
alive,  etc.* 

Bodies  of  those  who  succumb  six,  twelve  or 
eighteen    hours   after   the   attack,  exhibit   the   same 


*See  pages  112,  113. 


-  85  - 

cyanotic  appearance,  and  collapse  of  features,  as  in 
the  last  hours  of  life. 

The  circulatory  organs  and  the  blood  exhibit  the 
following  conditions:  When  death  is  early,  absence  of 
the  pericardial  fluid  is  noted,  or  it  is  scant  and  sticky; 
later  it  is  normal  or  slightly  increased.  The  portion  of 
the  pericardium,  which  lies  open  and  is  attached  to 
the  outer  side  of  the  heart,  i.e.,  the  visceral  layer,  is 
almost  constantly  the  seat  of  ecchymoses,  most  nu- 
merous towards  the  base  and  posteriorly;  it  is  rare  to 
find  on  the  parietal  layer.  Much  more  blood  appears 
in  the  right  heart  than  in  the  left — indeed  the  left 
heart  is  almost  always  empty, — which  is  apt  to  be  of 
a  pappy  appearance,  or  exhibit  soft  coagulable  and 
fibrinous  clots,  the  latter  gelatinous,  or  firm  and  color- 
less, either  of  which  conditions  may  be  present  in  the 
typhoid  stage. 

Lebert  remarks  he  once  found  a  fine  fibrinous 
clot  separated  in  the  form  of  a  membrane  spread  over 
the  whole  inner  surface  of  the  right  ventricle;  and 
that  the  perfectly  soft  dissolving  clots  which  are  often 
seen,  correspond  to  no  particular  stage  or  condition. 
He  also  made  a  chemical  examination  of  the  blood  of 
a  patient  dying  in  the  typhoid  stage,  that  revealed  no 
increase  either  of  urea  or  carbonate  of  ammonia  as  a 
constant  condition,  yet  adds  he  would  not  "like  to 
draw  conclusions  from  these  individual  examinations." 
Virchow  admirably  described  the  increase  in  the 
number  of  the  white  corpuscles  in  the  heart  clots. 


—  86  — 

As  to  the  respiratory  organs,  they  are  seldom 
affected  in  their  principal  portions,  though  occasion- 
ally secondary  diphtheritic  and  pseudo-membranous 
processes  are  encountered.  The  mucous  membranes 
of  trachea  and  bronchi  are  very  much  engorged  with 
blood  in  cases  of  early  death,  and  when  there  is  mod- 
erate hyperteraia  often  covered  with  mucus  in  which 
are  discovered  more  or  less  leucocytes;  in  exceptional 
cases  the  glands  of  the  trachea  are  considerably  swol- 
len. Ecchymoses  are  not  uncommon,  but  appear 
more  frequently  on  the  surface  of  the  lungs,  which 
latter  are  deeply  engorged  with  blood,  especially  in 
their  inferior  and  posterior  portions,  and  often  oede- 
matous.  Purulent  mucus  in  the  smallest  bronchi,  and 
the  anatomical  lesions  of  broncho-pneumonia  and  of 
typhoid-pneumonia,  are  conditions  sometimes  seen  in 
cases  of  death— after  three,  five,  or  eight  days;  and 
pleuritis  with  sero-purulent  effusion  also  belongs  to 
these  rarer  complications;  haemorrhagic  pulmonary 
infarctions  are  not  infrequent. 

The  isolated  oesophageal  glands  are  often  exces- 
sively swollen,  the  tube  itself  being  cyanotic  in  the 
algid  stage  and  ecchymosed  at  a  later  period.  In  his 
Zurich  autopsies,  Lebert  often  "  found  the  epithelium 
detached,  and  once  the  lower  part  of  the  oesophagus 
covered  with  fibrinous  diphtheritic  membranes." 
The  stomach  is  distended  and  filled  with  colorless 
fluid  in  cases  of  early  fatality,  but  later  is  empty  and 
collapsed;  when  death  occurs  after  the  third  or  fourth 


-  87  - 
day  it  is  apt  to  be  filled  with  yellowish-green,  sticky, 
gelatinous  or  mucous  fluid;  and  the  mucous  mem- 
brane, at  first  hypersemic,  shows  later  numerous 
ecchymoses,  and  occasionally  spots  of  bloody  infil- 
tration; when  death  occurs  late,  it  is  covered  with 
abundant,  tough,  thick  mucus,  and  perhaps  spots  of 
softening  that  probably  are,  in  part  at  least,  the  effects 
of  commencing  decomposition. 

The  most  marked  changes,  however,  are  found  in 
the  small  intestine.  Where  the  malady  runs  a  rapidly 
fatal  course,  the  intestinal  peritoneum  is  dry,  of  a 
rosy  color,  or  covered  with  a  light  layer  of  sticky 
fluid.  In  more  prolonged  cases  the  lesser  bowel  con- 
tains a  greenish  pultaceous  mas^  while  the  colon 
coecum,  etc.,  may  harbor  half-soHd  faeces;  in  the  early 
periods  the  contents  are  of  "rice-water"  character. 

During  the  attack  proper,  and  immediately  fol- 
lowing, the  glands  of  the  small  intestine  are  chiefly 
affected:  Brunner's  first,  a  condition  that  is  constant; 
then  the  isolated  and  agminated  glands,  the  former 
standing  out  in  relief,  their  size  varying  from  that 
of  a  millet  seed  to  a  pea;  Peyer's  patches  are  gran- 
ulated on  the  surface;  swelling  and  engorgement 
most  pronounced  toward  the  ileo-ccecal  valve.  Aside 
from  the  hypersemia  and  ecchymoses,  the  prominent 
glands  give  the  surface  a  pale,  milky,  or  yellowish 
appearance,  and  if  the  follicles  are  pierced  they  ex- 
ude a  whitish-gray  fluid  with  fine  granules  and  cell- 
nuclei,  without  leucocytes;    the  surface  is  smooth,  for 


the  most  part  deprived  of  epithelium  and  viUi,  and 
the  engorged  glands  admit  of  perfect  artificial  in- 
jection. 

These  typical  changes  are  generally  found  in  the 
first  forty-eight  hours;  Lebert  often  observed  the 
engorgement  began  to  diminish  at  the  end  of  from 
thirty-six  to  forty  hours,  though  in  some  cases  the 
glands  continued  infiltrated  for  four  or  five  days,  par- 
ticularly if  this  condition  persisted  in  the  tissues  im- 
mediately adjacent;  as  a  rule,  however,  infiltration 
rapidly  diminishes  at  the  end  of  the  second  or  in  the 
course  of  the  third  day,  when  the  glands  present  a 
flattened  and  somewhat  wrinkled  appearance,  later 
becoming  almost  granular;  they  are  still  prominent, 
however,  though  shrunken  in  circumference,  and  of 
yellowish-gray  (later  almost  slaty)  color;  occasionally 
a  blackish-gray,  brown,  or  brownish-red  pigment  is 
noticed,  especially  if  ecchymoses  have  previously 
existed.  In  the  second  week,  with  rare  exceptions, 
all  infiltration  and  congestion  disappears,  though  the 
glands  may  still  continue  thickened  and  abnormally 
colored.  In  the  first  period  Peyer's  patches  are  often 
found  converted  into  a  net-work,  the  follicles  fissured 
as  if  ruptured;  and  as  this  condition  is  present  in 
bodies  twelve  to  eighteen  hours  after  death,  the  sup- 
position it  is  a  post-mortem  phenomenon  is  manifestly 
incorrect.  In  cases  of  early  death,  in  some  epidemics, 
the  patches  are  ulcerated  as  in  typhoid  fever;  the 
glands  of  the  large  intestine,  also  are  found  swollen, 


prominent,  and  they  likewise  collapse  at  a  later  period, 
showing  the  same  retrograde  changes  as  those  of  the 
small  intestine. 

The  mucous  membrane  between  glands  may  share 
in  the  infiltration,  and  in  the  first  stage  is  very  deeply 
congested  (almost  cyanosed),  generally  ecchymosed 
or  with  extensive  extravasations,  so  that  great  patches 
of  mucosa  are  deeply  ensanguined,  a  condition  more 
frequently  observed  in  the  colon  than  in  the  small 
intestine;  at  an  early  stage  also  it  quite  often  is 
softened,  swollen,  even  oedematous,  a  condition  that 
later  is  confined  chiefly  to  spots;  extensive  softening 
of  either  the  small  or  large  intestine,  however,  is  rare. 
The  same  changes  in  color,  as  noticed  in  the  retro- 
grade metamorphoses  of  the  glands,  occur  throughout 
the  mucous  membrane,  though  less  pronounced.* 

The  anatomical  characters  of  secondary  colitis 
of  a  diphtheritic  or  dysenteric  nature,  are  seen  com- 
paratively often  in  some  epidemics,  in  others  are 
almost  entirely  absent.  The  mesenteric  glands  are 
quite  often  moderately  swollen,  but  usually  with- 
out much  infiltration. f 

"  The  spleen  is  in  general  small,  rather  wrinkled 
and   shrunken,  of  good  consistence,  and  moderately 


*Lebert  faithfully  pictures  all  these  details  in  his  "Atlas 
of  Pathological  Anatomy." — S. 

fFor  the  succeeding  anatomical  descriptions  I  must 
acknowledge  my  indebtedness  to  Herman  Lebert's  mono- 
graph on  the  Zurich  epidemics. — S. 


—  90  — 

supplied  with  blood,  though  sometimes  seen  enlarged 
in  consequence  of  apopletic  effusion;  in  cases  where 
cholera  complicates  typhoid  fever,  it  is  usually  en- 
larged. 

"  The  liver,  in  speedily  fatal  cases  is  often  hyper- 
Eemic,  and  shows  also  numerous  sub-peritoneal  ecchy- 
moses;  at  a  later  period  is  pale,  marble-yellow  or  red, 
with  isolated  islands  of  fatty  degeneration;  the  gall- 
bladder distended,  in  the  first  period  with  dark-brown 
bile,  later  of  a  bright-green  color,  semi-fluid,  resem- 
bling mucus.  Catarrh  of  the  biliary  passages,  even 
of  purulent  nature,  occasionally  develops  as  a  second- 
ary affection.  During  the  attack  the  bile  is  retained, 
but  later,  when  again  discharged,  during  a  protracted 
convalescence  or  in  the  typhoid  state,  it  seems  to  be 
abnormally  constituted — a  fact  which  makes  chemical 
examinations  at  this  period  much  to  be  desired. 

"The  bladder  usually  shows  nothing  abnormal; 
if  death  occurs  in  the  first  two  days,  it  is  contracted 
and  empty.  Still  I  have  found  in  it,  in  exceptional 
cases,  an  ounce  or  more  of  cloudy  albuminous  urine, 
even  after  the  disease  has  lasted  from  thirty-six  to 
forty  hours.  Usually  a  little  urine  is  found  in  the 
bladder  in  case  of  death  on  the  third  day,  though 
often  it  may  be  empty  even  when  death  occurs  on  the 
fourth  or  fifth  day.  The  mucous  membrane  of  this 
viscus,  in  the  beginning  takes  part  also  in  the  general 
cyanosis,  but  it  is  comparatively  little  marked  and 
of  little  consequence. 


—  91  — 

"  The  kidneys  may  early  take  part  in  the  disease 
processes,  and  even  when  death  occurs  in  from  sixteen 
to  twenty-four  hours,  there  is  always  observed  an 
increase  in  the  volume,  and  at  the  same  time  they  are 
generally  filled  in  both  the  cortical  and  medullary 
substances  with  blood  in  the  form  of  stripes  and 
punctated  injections,  and  on  the  surface  in  star-shaped 
and  marbled  spots,  with  numerous  and  thick  anasto- 
moses; the  superficial  inter-canalicular  vessels  and 
capillaries  of  the  Malpighian  glomeruli  also  share  in 
this  congested  condition,  and  ecchymoses  are  likewise 
not  infrequent.  Even  in  cases  of  death  in  the  second 
half  of  the  first  day,  the  cortical  substance  of  the 
kidneys  is  often  found  in  an  unmistakable  condition 
of  commencing  decoloration,  extending  even  from 
the  surface  deep  down  into  the  pyramids;  also  the 
capsules  are  frequently  abnormally  adherent.  The 
microscope  reveals  at  this  early  stage  a  remarkable 
epithelial  proliferation  in  the  urinary  canaliculi,  with 
cloudy  swelling  of  the  cell,  the  contents  of  which 
(consisting  of  numerous  albuminoid  granules)  may  be 
dissolved  by  acetic  acid.  Now  and  then  may  be  dis- 
covered, as  early  as  at  the  end  of  the  first  day,  distinct 
transparent  cylinders  in  the  interior  of  the  urinary 
canals.  The  kidneys,  therefore,  are  decidedly  affected 
on  the  very  first  day  of  a  pronounced  attack  of 
cholera. 

"  In  the  course  of  the  second  day  I  have  noticed 
either  the  same   commencing  decoloration,  or  more 


—  92  — 

marked  changes.  The  hyperaemia  is  now  either  con- 
fined to  spots,  or  general  with  simultaneous  decol- 
oration of  the  canals  and  cortex;  casts  are  present 
in  great  quantity — pressure  empties  from  the  papillae 
a  cloudy  albuminous  urine  containing  them,  and  not 
infrequently  crystals  of  uric  acid.  The  mucous  mem- 
brane of  the  calyces  and  pelves  is  usually  hyperse- 
mic,  with  injection  of  the  fine  vessels,  and  the  micro- 
scope reveals  progressive  degeneration  of  the  cells. 
In  the  course  of  the  third  day  the  decoloration  is 
so  far  increased  as  to  involve  the  whole  cortex,  and 
granulations  are  present;  the  blood  seems  to  be^ 
very  unequally  distributed;  the  surface,  uneven, 
rough,  and  closely  adherent  to  the  capsule.  The  cells 
continue  to  be  detached,  the  development  of  casts 
proceeds,  the  fatty  elements  increase  and  now 
show  themselves  as  granules  and  oil  drops  in  con- 
stantly increasing  quantity  in  the  epithelium  and  out- 
side of  it,  in  the  interior  of  the  canaliculi,  and  in  the 
casts. 

"  These  alterations  increase  in  the  typhoid  stage 
as  well  as  during  imperfect  convalescence.  The  kid- 
neys, according  to  many  accurate  measurements,  are 
from  one-sixth  to  one-third  larger  than  normal,  the 
granulations  more  abundant,  and  the  decoloration 
advanced  to  the  pyramids  and  even  between  them. 
The  substance  of  the  kidneys  is  now  softer,  more 
easily  torn,  and  infiltrated  with  a  dirty  yellow,  fatty, 
and  albuminous  fluid.     The  mucous  membrane  often 


—  93  — 
seems  thickened.  In  cases  where  death  occurs 
late,  all  the  signs  of  resolution  are  present;  in  favor- 
able cases,  all  these  seemingly  grave  lesions  quickly 
disappear,  and  the  kidneys  regained  their  normal 
condition.  Strange  to  say,  chronic  nephritis  caused 
by  or  incidental  to  cholera,  is  rare  "  (Lebert). 

The  chemical  examinations  of  the  various  organs 
undertaken  by  Staedeler,  in  Zurich,  in  1855,  yielded 
no  special  results.  Leucin  was  found  in  the  liver, 
and  small  quantities  of  uric  acid  in  different  organs. 
In  the  spleen,  leucin  was  once  detected;  in  other  cases 
inosite,  uric  acid,  and  much  pigment.  The  kidneys 
contained  comparatively  a  great  amount  urea,  some 
leucin,  bile-pigment,  and  uric  acid,  but  no  inosite. 

Glancing  now  at  the  whole  duration  of  cholera: 
For  the  period  of  incubation  may  be  allowed  from  five 
to  seven  days,  often  much  less,  sometimes  longer. 
Where  orodromata  exist,  their  average  duration  is 
from  one  to  three  days.  Next  comes  the  stage  of 
attack,  which  is  the  second,  or  (when  prodromata 
are  lacking)  at  times  the  first  stage;  this  may  prove 
fatal,  in  from  six  to  eight  hours,  or  even  less,  but 
varies  in  fairly  severe  cases  from  twelve  to  twenty- 
four   hours. 

With  the  end  of  the  attack  proper  (the  second 
stage)  comes  the  period  of  reaction,  usually  at  the 
end  of  from  eighteen  to  twenty-four  hours,  and  now 
the  patient  either  dies  from  cyanotic  asphyxia,  or  the 
reaction  is  perfectly  established  and  the  real  cholera 


—  94  — 
is  happily  and  definitely  over.  The  stage  of  reaction 
may  pass  into  speedy  convalescence,  which  may  ter- 
minate in  the  second  half  of  the  first  week;  or  the 
convalescence  is  protracted,  either  without  further 
critical  symptoms  or  with  transition  into  the  typhoid 
stage.  The  typhic  stage,  in  turn,  may  lead  to  fatal 
or  fortunate  termination  in  the  last  days  of  the  first, 
or  in  the  first  days  of  the  second  week  of  the  whole 
duration  of  the  disease.  It  is  a  rare  exception  for 
patients  to  die  of  cholera  after  ten  or  twelve  days,  or 
to  be  affected  with  long-continued,  bad  sequelae, 
though  a  weak  invalid  condition  may  persist  for  a 
long  time  as  the  result  of  defective  nerve  action. 

Finally,  it  must  be  remarked  that  it  is  impossible, 
no  matter  what  the  scope  of  the  work,  to  describe  all 
the  sequelae  and  complications  of  cholera;  where  the 
circulation  is  so  profoundly  disturbed,  and  the  nerve 
toxaemia  so  virulent,  the  most  multiform  local  con- 
gestions and  inflammations  are  possible. 


CHAPTER  VII. 

CHOLERA    DIARRHOEA   AND    CHOLERINE. 

The  mildest  form  of  cholera  is  that  simulating  a 
simple  diarrhoea,  in  which  the  evacuations  follow  each 
other  more  or  less  closely,  are  very  copious  and 
watery,  but  not  altogether  devoid  of  consistence  and 
color,  and  retain  in  some  degree  the  characteristic 
faecal  odor;  they  perhaps  are  not  accompanied  by 
colicky  pains  or  tenesmus,  and  cause  no  constitutional 
or  other  disturbance  except  a  moderate  degree  of  de- 
pression and  relaxation.  Such  frequently  do  not  ap- 
appear  in  official  lists,  but,  as  Niemeyer  pertinently  ob- 
serves, "though  not  considered  by  the  police  as  chol- 
era, they  should  be  so  recognized  by  science.  This  is 
shown: 

(i)  "By  the  larger  number  of  cases  of  diarrhoea 
occurring  during  cholera  times,  although  almost  all 
sensible  people  carefully  avoid  errors  of  diet,  catch- 
ing cold,  and  other  sources  of  injury: 

(2)  "  The  great  obstinacy  of  these  cases: 

(3)  "  The  well  known  transportation  of  the  dis- 
ease by  persons  suffering  therefrom: 

(4)  "  Especially  by  the  numerous  transformations 
of  simple  cholera  diarrhoea  into  the  most  severe  form  of 
the  malady. — Many  patients,  especially  of  the  poorer 
classes,  worried  by  a  diarrhoea  which  will  not  give  way 
to  domestic  remedies,  go  to  the  doctor  for  a  prescrip- 


_  96  - 

tion  at  noon,  and  in  the  evening  lie  cold,  pulseless,  and 
cyanotic,  almost  in  a  hopeless  state.  ...  I  deem 
it  much  more  important  to  determine  the  frequent 
occurrence  of  gradual  transformation  from  simple 
cholera  diarrhoea  to  so-called  cholerine,  and  to  malig- 
nant cholera,  and  to  prove  the  identity  of  these  three 
forms,  than  to  seek  for  pathognomonic  signs  of  epi- 
demic cholera."* 

Cholera  diarrhoea  and  cholerine,  which  constitute 
the  milder  forms  of  the  disease,  during  the  preva- 
lence of  epidemics  also  present  varied  phases,  and 
more  than  all  varied  characteristics  in  different  epi- 
demics. Lebert,  Zehnder,  Karl  Liebermeister,  and 
others,  have  noted  how  greatly  personal  predisposi- 
tion favors  or  inhibits,  as  the  case  may  be,  extension 
or  repression;  that  an  imported  case  in  any  one 
locality  may  be  confined  to  a  single  individual,  to  a 
single  house,  even  to  single  room  in  a  dwelling,  while 
at  other  times  one  case  may  be  the  focus  of  a  raging 
pestilence.  Thus  the  history  of  different  epidemics,, 
particularly  in  large  cities,  shows  the  greatest  variety 

*"Text  Book  of  Practical  Medicine,"  Vol.  ii.  New 
York,  1884. 

*  How  probable  it  is  that  a  swiftly  fatal  attack  is  de- 
veloped from  profound  toxicity  of  the  central  nervous  system 
through  the  medium  of  the  absorbents,  especially  those  of 
the  portal  area,  by  an  excess  of  the  cholera  poison,  is  shown 
by  phenomena  developed  in  acute  arsenical  poisoning,  which 
has  several  times  been  mistaken  for  true  cholera  (see  p.  107)., 
— S. 


—  97  — 

of  effect,  accordingly  as  the  cholera  poison  finds  con- 
ditions for  development  more  or  less  suitable.  Again, 
it  has  been  observed,  as  a  rule,  that  prodromic  diar- 
rhoeas are  more  frequent  and  more  widely  diffused  in 
malignant  and  extensive  epidemics  than  in  those  of 
less  extent.  Yet  Lebert  declares,f  in  the  great  epi- 
demic in  Paris  of  1849,  which  is  computed  to  have 
claimed  something  like  ten  thousand  victims,  premon- 
otory  intestinal  flux  was  wholly  absent  in  from  five  to 
ten  per  cent,  of  the  pronounced  cases;  in  Zurich  it 
was  absent  in  ;^^.^  per  cent,  of  pronounced  cases;  and 
that  absence  or  presence  of  prodromic  diarrhoea  had 
no  apparent  influence  in  determining  the  ultimate  re- 
sult of  the  attack,  as  the  recoveries  and  deaths  were 
about  equally  proportioned  in  regard  to  this  symptom. 
Also,  he  adds,  "  I  found  that  the  prodromic  diarrhoea 
was  absent  in  seven-eights  of  the  cases  of  true  choler- 
ine (with  colored  stools).  In  Paris  as  well  as  in  Zurich 
and  Breslau,  in  1866  and  1867,  I  saw  a  number  of 
cases  of  diarrhoea  which  were  due  to  the  influence  of 
cholera,  recover  without  treatment  and  without  sub- 
sequent cholera.  On  the  other  hand,  in  July  and  the 
beginning  of  August,  1866,  I  witnessed  such  obstin- 
ate and  violent  cases  of  cholera  diarrhoea  in  the 
Breslau  garrison  of  cuirassiers,  where  I  had  charge  of 
a  large  ward  of  wounded  patients,  that  it  required  the 
utmost  effort  to  prevent  on  outbreak  of  cholera." 

fZiemssen's  "  Cyclopoedia  of  Practical  Medicine."  New 
York,  1874. 


There  is  no  marked  distinction  between  common 
intestinal  catarrh  and  cholera  diarrhoea,  yet  the  latter 
presents  certain  definite  peculiarities  which  are  en- 
titled to  consideration  in  seeking  a  definite  diagnosis. 

Cholera  diarrhoea  is  usually  sudden  and  unex- 
pected: As  already  remarked,  is  apt  to  be  excited,  or 
receive  its  ultimate  development,  through  "taking 
cold"  or  errors  of  diet;  and  to  intemperance  in  the  habit- 
ual use  of  alcoholic  beverages  more  than  any  other 
single  cause  may  the  proclivit)'-  to  this  form  of  flux 
be  ascribed. 

Loss  of  appetite,  thirst,  indigestion,  are  either 
present  or  absent  in  only  slight  degree;  patients  gen- 
erally, however,  complain  of  an  excessive  feeling  of 
lassitude — are  extraordinarily  weak,  feeble  and  uncom- 
fortable,— and  not  unfrequently  exhibit  despondency, 
out  of  all  proportion  to  the  frequency  or  quantity  of 
the  flux. 

There  is  nothing  specially  peculiar  about  the 
stools  other  than  they  are  simply  fluid,  as  in  any 
diarrhoea;  often  there  are  but  two  or  three  dis- 
charges during  the  twenty-four  hours,  more  rarely 
from  six  to  eight,  and  are  more  apt  to  supervene 
during  the  night,  and  to  be  accompanied  by  distressing 
rumblings  and  gurglings. 

In  some  cases  the  diarrhoea  persists  only  a  few 
hours  or  days;  in  others,  one  or  two  weeks,  with  con- 
siderable intermissions,  during  which  the  individual 
feels  perfectly  well.   Sometimes  it  regularly  intermits  or 


—  99  — 

remits  during  the  whole  course  of  the  epidemic  in  that 
particular  locality,  and  ceases  only  as  the  latter  dis- 
appears. Even  in  the  milder  cases  of  cholera  diar- 
rhoea may  be  sometimes  observed  individual  evidences 
of  cholera  proper,  such  as  suppression  of  urine,  light 
cramps  in  calves,  colorless  and  odorless  "rice-water" 
stools,  that  are  merely  of  temporary  duration,  and  are 
more  generally  characteristic  of  cholerine.  Neither 
is  it  a  rare  occurrence  for  a  cholera  diarrhoea,  which 
remains  in  other  respects  without  danger,  to  suddenly 
increase  in  virulence,  with  violent,  quickly  repeated 
stools,  as  in  true  cholera,  and  yet  cease  quickly  and 
be  followed  by  prompt  recovery. 

Cholerine,  as  the  term  indicates,  is  a  lesser 
cholera;  in  other  words,  it  is  a  condensed  picture  of 
the  mildest  form  of  the  more  grave  attack,  and  may, 
indeed  often  does,  present  some  of  the  serious  symp- 
toms peculiar  to  the  latter.  It  is  usually  ushered  in 
by  such  prodromal  symptoms  as  malaise,  headache, 
diminution  of  appetite,  muscular  or  general  physical 
weakness,  of  at  least  twelve  and  often  twenty-four 
hours'  duration;  there  is  also  general  restlessness,  in- 
somnia— or  at  least  the  hours  of  sleep  are  productive 
of  discomfort  rather  than  rest;  and  the  attack  culmin- 
ates in  the  middle  of  the  night  or  early  morning  by 
sudden  awakening  due  to  demand  for  stool.  Now 
is  observed  a  copious  yellowish-brown,  almost 
watery  discharge,  with  characteristic  diarrhoeic  odor, 
but  succeeded  by  a  second  still  more  fluid,  and  others 


again  at  brief  intervals  to  the  number  of  three,  six,. 
eight,  twelve  or  more,  until — when  they  become  very 
numerous — there  is  gradually  less  and  less  evidence 
of  odor,  color,  or  form,  and  they  assume  a  decided 
"  rice-water  "  character. 

With  the  first  evidence  of  diarrhoea,  nausea  is 
apt  to  supervene  which,  after  repeated  stools,  is  merged 
into  emesis,  the  ejected  matter  being  first  of  a  yellow- 
ish green  hue  with  intensely  sour  bitter  taste,  very 
fluid  in  character,  finally,  perhaps,  colorless,  whey- 
like, showing  a  deposit  very  like  grains  of  bruised 
rice;  after  a  few  times,  the  quantity  is  lessened,, 
the  act  itself  becoms  more  infrequent,  and  finally  it 
ceases  altogether  after  a  few  hours;  this  vomiting  is  not 
at  all  painful,  retching  being  a  comparatively  rare 
concomitant,  but  the  fluid  pours  forth  in  a  manner 
resembling  an  easy  act  of  regurgitation,  though  its 
profuse  quantity  is  very  suggestive  of  its  choleraic 
nature.  The  sufferer  in  the  meantime  becomes  very 
much  reduced;  but  with  the  cessation  of  vomiting 
and  diarrhoea,  either  recovers  very  rapidly,  or  tem- 
porary typhoid  symptoms  manifest  themselves.  While 
complete  convalescence  may  be  established  in  a  few 
days,  it  is  often  a  matter  of  two  or  three  weeks.  In 
the  favorable  cases  of  cholerine,  convalesence  occurs 
in  two,  three  or  four  days. 

Sometimes  the  inclination  to  diarrhoea  lingers  for 
some  days  after  the  convalescing  stage  has  set  in, 
with  all  the  concomitants  of  anorexia,  borborygmus. 


occasionally  twinges  of  colic,  etc.;  not  infrequently 
also  there  is  continued  nausea,  especially  after  the 
ingestion  of  food;  and  a  distressing  tendency  toward 
cramping  of  muscles  of  legs  (calves)  is  more  or  less 
apparent  according  to  the  severity  of  the  attack. 
Lebert  remarks  he  has  also  seen  moderate  cooling  of 
extremities;  that  he  personally  experienced  almost 
complete  aphonia  for  twenty-four  hours  after  a  seiz- 
ure, and  di'd  not  fully  recover  his  voice  until  "at  the 
end  of  several  days;  "  also  noticed  considerable  re- 
duction in  the  quantity  of  urea,  as  well  as  the  tem- 
porary occurrence  of  albumen  and  casts  in  very  dark 
scanty  urine.  It  is  perhaps  needless  to  say  that 
gastric  catarrh  not  infrequently  interferes  with  con- 
valescence; that  errors  in  diet  may  lead  to  fatal  re- 
lapse; and  that  the  temporary  typhoid  state,  when  it 
supervenes,  is  manifested  by  such  symptoms  as  head- 
ache, vertigo,  roaring  in  ears,  cloudiness  of  vision, 
great  debility,  sopor,  etc. 

It  is  also  of  interest  to  remember  that  where 
this  "little  cholera"  is  seen  in  houses  and  families, 
frequently  in  the  course  of  a  few  days  a  malignant 
asphyctic  cholera  will  develop,  and  that  it  therefore 
may  lead  to  genuine  and  fatal  cholera  when  the  in- 
dividual (or  individuals)  is  sufficiently  receptive  toward 
the  poison;  that  cholerine  may  itself  prove  fatal  in 
weak  and  aged  patients;  and  when  cholera  prevails  in 
a  large  city  with  great  severity,  the  number  of  per- 
sons attacked  with  real  cholera  is  always  relatively 


smaller  than  those  attacked  with  cholera  diarrhoea 
and  cholerine.  Moreover,  cholera  diarrhoea  and 
cholerine  occur  much  more  frequently  in  places 
some  distance  from  the  centres  of  the  disease,  while 
true  cholera  prevails  at  these  centres.  In  all  these 
cases  it  is  probably  the  diminished  capacity  of  the 
surroundings  for  infection  accounts  for  the  relatively 
greater  dissemination  of  the  lighter  forms  of  the  dis- 
ease; but,  as  just  remarked,  these  lighter  forms  by 
rapid  multiplication,  or  increased  virulence  of  the  poi- 
son of  the  disease,  under  favorable  conditions  of  the 
organism,  may  lead  to  dangerous  attacks  of  cholera. 

In  enumerating  these  phases  of  the  epidemic 
more  specifically,  it  must  be  understood  that'  in 
differentiating  the  three  forms  there  is  no  reces- 
sion from  the  position  I  shall,  in  a  later  chapter, 
endeavor  to  establish  that  all  are  de  facto  cholera. 
And,  further,  it  may  be  added,  it  is  a  matter  of 
great  personal  doubt  whether  any  cholera  is  derived 
from  a  special  germ  or  poison,  other  than  that 
resultant  upon  any  common  decomposition;  or  possi- 
bly that  the  Asiatic  form  is  due  to  the  common  poison 
supplemented  by  an  imported  one,  that  after  all  is 
but  the  same  intensified  in  its  original  habitat  and  by 
transmission;  or,  again,  that  all  cholera  is  due  to  a 
poison  of  common  decomposition  that  was  foreign 
originally,  but  since  importation  has  become  in  a 
sense  acclimated.  There  are  few  medical  men  who 
have  not  seen  cholera  nostras — or  as  it  is  termed  in 


—  I03  — 

this  country,  sporadic  ciiolera,  or  cholera  morbus — 
with  positive  "  rice-water  "  discharges,  colorless  and 
odorless,  outside  of  the  period  of  any  epidemic;  I 
have  repeatedly  encountered  such  in  my  own  experi- 
ence, and  in  the  service  of  others;  and  Lebert,  J.  M. 
and  D.  D.  Cunningham,  Bouchard,  Leiter,  Zehnder, 
Fayrer,  Niemeyer,  Trousseau,  Semmola,  Tanner, 
Sir  Wm.  Aitken,  and  a  list  who  are  fairly  "  Legion,"* 
corroborate,  and  have  also  expressed  the  opinion 
cholera  infantum  is  only  cholera  sporadica,  modified 
by  age. — A  propos  of  this  it  may  be  mentioned  that 
Chas.  Talamonf  has  recently  adduced  considerable 
evidence  tending  to  demonstrate  the  unity  of  these 
maladies  : 

He  points  out  that  ravages  of  cholera  diarrhoea,  of 
epidemic  nature,  occur  from  time  to  time  without  any 
evidence  of  a  foreign  or  imported  factor,  in  localities 
in  which  true  cholera  has,  sometime  or  another,  mani- 
fested itself;  and  likewise  reference  is  made  to  a  recent 
epidemic,  the  exact  prototype  of  another  occurring  in 
1866,  in  the  neighborhood  of  Paris,  clinically  diag- 
nosed as  cholera  nostras,  but  which  on  investigation 
in  no  way  differed  pathologically  from  the  so-called 
Asiatic  malady.  The  cholera  bacillus  was  demon- 
strated in  the  dejections  also. 


*See    "Nature    and    Treatment  of    Sporadic    Cholera" 
by  Alex.  Harkin.     W.  Renshaw,  London,  1885. — S. 
\  La  Medicine  Moderne,  1892. 


CHAPTER  VIII. 

SPECIFIC     PATHOLOGY. 

I  have  been  thus  particular  in  enumerating  the 
general  outlines  and  peculiarities  of  this  disease, 
which  presumably  are  familiar— or,  at  least,  they 
should  be, — to  every  medical  man,  in  order  to  more 
forcibly  call  attention  to  their  physiologico-therapeu- 
tical  relations.  It  has  already  been  remarked,  the 
neurotic  character  of  the  disease  is  most  apparent, 
and  that  there  is  no  relation  between  the  quantity  of 
fluid  lost  by  the  bowel  and  stomach  and  the  malig- 
nancy of  the  onslaught. 

The  simple  diarrhoea  which  ushers  in  an  attack, 
or  that  may  constitute  almost  the  only  manifestation 
of  the  malady,  is  especially  remarked  upon  by  all 
observers  for  its  stubborn  character;  it  yields  to  none  of 
the  customary  remedies,  and  is  influenced  scarcely  at 
all  by  opiates  or  astringents.  This  presupposes  a 
lesion  deeper  than,  and  behind,  the  visceral  and  tho- 
racic organs  that,  apparently,  are  most  involved,  and 
one  has  no  option  but  to  refer  the  same  to  the  central 
nervous  system. 

In  1870  M.  F.  Moreau,  and  also  S.  G.  Vasquez, 
demonstrated  by  a  series  of  observations, — corrobo- 
rating those  of  Edward  Pfliiger  and  Otto  Nasse, 
and  since  repeated  by  many  others, — the  influence 
of  the  sympathetic  nerves  upon  the  intestinal  canal, 


—  I05  — 
which  influence  is  most  pertinent  as  evidencing  the 
source    and    character    of    the   watery    diarrhoea  in 
cholera,  and  likewise  its  sudden  occurrence  without 
any  form  of  premonition  or  warning. 

Both  found  when  these  nerves  were  divided,  the 
portion  of  the  intestines  segregated  by  the  operation 
rapidly  filled  with  clear  alkaline  fluid,  colorless  and 
slightly  opaline— except  as,  at  the  outset,  they  might 
become  mixed  with  material  still  remaining  within  the 
gut, — which  precipitated  flocculi  of  organic  matter  on 
boiling.*  Transudation  of  watery  fluid  into  the  in- 
testines, due  to  capillary  diffusion,  takes  place  as  the 
result  of  paralysis  of  the  sympathetic;  the  occur- 
rence of  sudden  hypersemias,  transudations,  and 
ecchymoses,  in  some  thoracic  or  abdominal  organ, 
may  have  a  neurotic  basis,  f 

Paralysis  or  hyperaethesia  of  the  sympathetic — 
conditions  that  differ  physiologically  only  in  degreeX — 
induce  vomiting,  retching,  etc.  When  the  nerves  are 
divided  below  the  solar  plexus,  which  is  situated  in 
most  intimate  relation  with  the  splanchnic  area,  the 


*Vide  Flint's  "  Physiology  of  Man."     New  York,  1874. 

f  Vide  Carpenter,  Dalton,  Draper,  Kirk,  Paget,  Landois 
and  Sterling,  Foster. 

|:There  are  several  circumstances  that  support  this 
view,  chief  of  which  are,  the  association  of  pain  with  both 
hyperffithesia  and  numbness,  especially  in  highly  sensitive 
parts,  and  the  difficulty  of  differentiating  the  condition  pro- 
ducing the  one  from  the  other.     "It  is  clear,"  says  Dr.  C. 


—   io6  — 

secretion  of  urine  and  urea  sinks  quickly  to  a  minimum, 
and  may  perhaps  cease  entirely,  as  shown  by  Coni 
Peyrani,  who  is  corroborated  by  Brown-S^quard  and 
Claude  Bernard.  These  latter  authors,  moreover^ 
further  observed  that  partial  segregation  of  the  sym- 
pathetic below  the  inferior  cervical  ganglion  induced 
marked  depression  of  temperature,  made  more  mani- 
fest toward  the  surface  and  in  the  cutaneous  area,  but 
succeeded  by  rapid  increase  of  temperature  after 
death.  "  Paralysis  of  vaso-motor  nerves  decreases 
temperature,"  says  James  Kirk;  and  the  sympathetic 
pertains  to  the  vaso-motoric  system. 

Lebert  declares  that  while  the  most  important 
and  constant  anatomical  clinical  localization  of  the 
disease  occurs  in  the  small  intestines,  there  "  is  a  pos- 
sibility the  often  so  violent  discharges  of  serum  are 
incited  by  the  central  nervous  system,  the  excitement 
originating  in  the  vaso-motor  centres.'''  Again:  "  The 
cerebro-spinal  fluid  is  entirely  absent  in  cases  where 
death  occurs  at  an  early  period,  or  is  present  only  in 
slight  quantity  and  of  almost  pasty  consistence.  But 
I  have  seen  it  more  copious  when  death  has  occurred 


Handifield  Jones,  "there  is  no  opposition  between  them: 
all  are  present  together.  Now  paralysis,  numbness,  anaes- 
thesia, hyperaesthesia  are  evidently  failure  of  functional 
power;  and  of  the  same  import  is  the  occurrence  of  various 
degrees  of  paralysis,  or  of  paresis,  paraesthesia,  analgesia, 
which  may  be,  and  are,  associated  as  analogous  affections  of 
he  motor  and  sensory  nerves." — S. 


—  I07  — 

at  the  end  of  thirty-six  hours;  and,  where  death  oc- 
curs still  later,  it  may  even  exceed  the  normal  amount. 
The  pia  mater  loses  its  marked  hypersemia  in  a  more 
protracted  course  of  the  disease,  and  becomes  dry, 
perhaps  icteric.  The  fluid  of  the  ventricles  remains 
scanty  even  when  death  occurs  at  later  periods. 
*  .  *  *  Ecchymoses  of  the  external  surface  of  the 
brain  (pia),  or  on  the  internal  surface  (ependyma) 
are  not  rare.  There  may  be  capillary  effusion  into 
the  pons,  and  once  I  saw  a  fresh  effusion  of  blood 
between  the  dura  and  arachnioid." — All  this  is  cer- 
tainly suggestive. 

Again,  it  must  be  borne  in  mind  that  while  "  rice- 
water  "  stools  accrue  to  all  choleraic  attacks,  except  the 
most  pronounced  and  violent  form  known  as  cholera 
asphyxia,  cholera  siderans  or  cholera  sicca,  they  are,  per 
se,  by  no  means  pathognomonic,  but  result  always 
from  influences  of  the  most  powerful  character  brought 
to  bear  upon  the  central  nervous  system.  They  are 
a  concomitant  of  terror  and  mental  purturbation;  of 
heat  apoplexy;  of  arsenical  poisoning;*  of  autogenetic 


*  How  probable  it  is  that  a  swiftly  fatal  attack  is  de- 
veloped through  nerve  irritation  manifested  in  a  portion  of 
the  small  intestine,  is  shown  by  the  action  of  arsenic,  which 
may  induce  fatal  poisoning  in  a  few  hours,  with  symptoms 
perfectly  resembling  those  of  cholera.  Late  in  the  autumn 
of  1854,  a  woman  who  had  been  suddenly  taken  sick  during 
a  criminal  trial,  entered  Lebert's  Clinic  in  Zurich.  She  died 
in    hospital   after  a  number  of   violent,  perfectly   colorless, 


—  io8  — 

toxication  by  specific  ptomaines;  of  toxication  by  cer- 
tain alkaloids,  etc.;  and,  moreover,  the  dejections,  as  in 
cholera,  hold  a  profusion  of  material  commonly  sup- 
posed to  be  intestinal  epithelium  (but  which  is  really 
the  result  of  transformation  taking  place  in  the  effusion 
of  blood  plasma),  and  likewise  contain  serum-albumen, 
mucin,  and  a  large  amount  of  salts,  chloride  of  so- 
dium preponderating  to  such  an  extent  as  often  to 
exceed  in  amount  all  organic  matters.*  But  the 
blood  in  cholera,  as  an  almost  invariable  rule,  is  free 
from  bacteria,  either  actual  or  potential ;  this  is  the 
case  as  well  shortly  after  death  as  during  life,  and 
holds  in  regard  to  every  stage  of  the  disease. 

Further,  choleraic,  arsenical,  and  alkaloidal  poison- 
ings, of  a  particular  class,  likewise  thermic  apoplexy, 
alike  induce  a  high  specific  gravity  of  the  blood — an 


very  copious  discharges.  The  small  intestine  showed  an 
immense  accumulation  of  colorless  fluid,  and  clinical  ex- 
amination of  the  contents  of  the  stomach  revealed  unmis- 
takable evidences  of  arsenical  poisoning.  Lebert  further 
adds:  "  In  the  summer  of  1847  I  was  told  by  Louis,  in  the 
Hotel  Dieu,  that  the  Duke  of  Choiseul,  who  had  been  ar- 
rested the  day  before  for  the  murder  of  his  wife,  died  sud- 
denly of  cholera,  and  he  wondered  at  it  greatly,  because 
cholera  was  nowhere  prevalent.  Louis  was  the  Duke's 
physician  and,  as  is  well  known,  one  of  the  greatest 
diagnosticians  of  our  time;  nevertheless  it  soon  turned  out 
the  Duke  had  poisoned  himself  with  arsenic." — S. 

*  The  proportion  of  solid  constituents  in  all,  varies  from 
i.20to  2.40. — S. 


—   109  — 

average  of  1.0701,  against  1.0503  in  health, — which  is 
remarkably  tough  and  viscid,  the  corpuscles  increased 
in  number  but  abnormally  impoverished  as  to  salts; 
the  amount  of  fibrin  is  unaffected,  but  the  serum  is 
very  dense,  extremely  rich  in  albumen,  and  contains 
more  phosphates  and  potash  salts  (though  less  col- 
lectively) than  normal;  moreover,  contains  some  urea, 
together  with  extractive  matters  that  seem  to  possess 
the  quality  of  rapidly  converting  the  former  into  car- 
bonate of  ammonia  (Day,  Hoppe-Seyler,  C.  Schmid). 
Draper  also  remark:  "  In  cholera  the  constitution  of 
the  blood  is  so  changed  that  the  cells  can  no  longer 
carry  oxygen  into  the  system;  the  heat-making  pro- 
cesses are  put  a  stop  to,  and  the  temperature  declining, 
the  body  becomes  of  marble  coldness  characteristic 
of  this  terrible  disease,"— phenomena  that  accrue  to 
muscarine  and  certain  other  alkaloidal  poisonings. 

Armand  Trousseau  says  the  varied  and  peculiar 
symptoms  exhibited  by  asphyctic  cholera,  can  be  ex- 
plained only  by  referring  to  a  poison  having  specific 
effect  upon  the  nervous  system;  and  Wilhelm  Erb 
adds,*  refering  to  poisons  as  a  class:  "  They  cause 
lasting  paralysis,  as  a  rule,  only  when  their  action  is 
slow  and  repeated,  more  rarely  when  they  are  acute; 
they  cause  the  most  varied  forms  of  paralysis  and 
paraplegia,  from  simple  weakness  and  paresis  to  com- 


*  Ziemssen's  "  Cyclopoedia  of  the  Practice  of  Medicine." 
New  York,  1874. 


plete  paralysis,  .  .  with  or  without  disturbance  of 
sensibility. 

One  of  the  functions  of  the  sympathetic,  if  the 
deductions  of  Jno.  W.  Draper  maybe  accepted,  is  "  the 
equalization  or  balancing  of  nerve  force,  storing  up 
all  transient  excesses,  and  providing  for  all  transient 
deficiences." 

This  sympathetic  nerve  system,  too,  transmits  sen- 
sations so  tardily  that  the  economy  may  be  violently, 
even  fatally  poisoned  through  the  central  nerve  organs, 
long  before  the  customary  effects  are  manifested  by 
the  usual  symptomatology.  Says  Jno.  C.  Dalton  :* 
"  Evidences  of  sensibility  are  much  less  acute  than  in 
other  nerves,  and  show  themselves  only  after  prolonged 
application  of  the  exciting  cause''! 

Damp,  cold,  malaria,  chorea,  and  certain  poisons, 
all  act  in  the  same  precise  way  by  deranging  mole- 
cular nutritive  actions  of  the  nerve  structure,  and  so 
unfitting  the  latter  to  fulfil  its  function  :  and  anaesthe- 
sia and  hypersesthesia  are  alike  failures  of  func- 
tional power,  varying  only  in  degree.  Again  hyper- 
sesthesia and  irritation  may  be  the  result  of  dual 
action,  viz  :  Of  poisoning  of  cerebral  centers,  and  of 
local  irritation. 

The  foregoing  most  certainly  sheds  new  and  most 
welcome  light  on  the  pathology  of  cholera,  especially 
the  frequent  steady  march  to  fatality  during  moments 


"Human  Physiology."     New  York,  i8go. 


that  promise  so  much  in  the  way  of  amendment  as  to 
mislead  the  most  astute  observer. 

And  herein  perhaps  Hes  the  arrow  that  fatally 
pierces  the  joints  of  our  therapeutic  armor,  when  is 
sought  to  oppose  the  disease  by  treating  that  which 
is  most  apparent — the  local  manifestation;  the  evil 
has  been  wrought  long  before  its  faintest  symptom- 
atology is  made  appreciable  to  human  understanding, 
and  consequently  is  apt  to  be  beyond  the  power  of 
any  method  or  theory  of  antagonism  or  revulsion, 
however  perfect.  In  cholera,  then,  often  the  patient 
may  be  fatally  poisoned  before  the  presence  of  the 
disease  can  be  detected  or  even  surmised. 

In  fades  cholerica  is  observed  a  condition  that 
may  be  duplicated  by  segregation  of  the  superior 
cervical  ganglion  of  the  sympathetic,  or  by  its  extir- 
pation; the  eyeball  is  drawn  back  into  the  orbit, 
causing  partial  closure  of  the  upper  and  lower  lids 
and  flattening  of  the  corneas;  the  countenance  be- 
comes withered  and  ghastly;  in  short,  is  brought 
about  a  cadaverous  aspect  that  sometimes  precedes 
death  in  long-standing  disease,  but  here  supervenes 
in  an  hour  or  two. 

When  death  occurs  during  the  invasion  of  the 
disease  or  in  the  stage  of  collapse,  in  the  more  marked 
cases  the  appearances,  as  previously  shown,  are:  The 
bodies  remain  warm  for  some  time — the  temperature 
may  rise  after  death,  perhaps  even  to  103°  Farh.,  and 
so  continue  for  several  hours  (note  the  observations 


of  Brown-Sequard  and  Claude  Bernard,  before  cited); 
the  rigor  mortis*  soon  appears  and  is  extended  over  a 
preternaturally  long  period  of  time;  the  muscles  (par- 
ticularly of  hands,  arms,  and  legs)  sometimes  exhibit 
a  peculiar  spasmodic  twitching  before  rigor  mortis 
sets  in,  so  much  so  that  the  Cholera  Gazette  for  1832 


*  Professor  A.  Paltauf  read  a  paper  before  the  Associa- 
tion of  German  Physicians,  at  Prague,  on  some  experiments 
made  to  show  the  causal  connection  between  rigor  mortis  and 
deaths  from  poison.  For  the  purpose  of  these  experiments 
such  poisons  were  used  as  were  known  to  exert  a  certain  in- 
fluence on  the  muscular  system,  either  by  acting  directly 
on  the  muscle  substance,  or  indirectly  by  affecting  the  ner- 
vous system.  Amongst  the  poisons  belonging  to  the  first  series , 
curare  always  considerably  delays  the  occurrence  of  rigor  mor- 
tis. Amongst  those  acting  on  the  central  nervous  system, 
strychnine,  picrotoxin,  camphor,  and  the  salts  of  ammonium 
and  arsenic,  accelerate  the  occurrence  of  rigor  mortis.  The 
aceleration  is  still  more  increased  by  artificially  prolonging 
the  stimulation  of  the  muscular  system,  but  is  again  arrested 
on  the  occurrence  of  paralysis.  Veratrine  and  physostig- 
mine  cause  only  a  slight  acceleration  of  the  rigor  mortis,  but 
with  caffeine  and  its  chemical  derivatives — the  rhodan  salts 
— this  acceleration  becomes  considerable.  To  study  the  in- 
fluence of  the  nervous  system  at  the  time  of  occurrence  of 
the  rigor  mortis,  Paltauf  divided  the  nerves  and  the  spinal 
cord,  with  the  result  that  the  more  a  muscle  had  been  stimu- 
lated by  the  poison  the  sooner  was  the  rigor  mortis  observed, 
independently  of  its  connection  with  the  spine,  if  such  con- 
nection existed.  The  reaction  of  the  rigid  muscles  was  in 
the  case  of  many  poisons,  as  has  been  generally  believed, 
acid.     Other  poisons,  however  (such  as  camphor,  ethyl-theo- 


—  113  — 

declares  the  soldiers  were  accustomed  to  bind  the 
limbs  of  their  dead  comrades  to  the  bed-frames  in 
order  to  prevent  shocking  the  more  timid  of  the 
living.*     All  these   manifestations  point  indubitably 


bromine  and  the  rhodan  salts),  gave,  contrary  to  the  general 
assumption,  an  alkaline  reaction.  This  alkaline  reaction 
affected,  however,  only  the  anterior  portion  of  art  animal  in 
which,  after  the  poisoning,  the  cord  had  been  divided.  The 
posterior  part  of  the  animal,  in  which  the  rigor  mortis  was' 
delayed,  showed  the  usual  acid  reaction  until  the  alkaline 
reaction  of  putrescence  took  place.  Where  the  reaction  of 
the  anterior  portion  of  the  animal  was  alkaline  it  often  be- 
came, after  the  reduction  of  the  rigidity  had  passed  off, 
neutral  or  slightly  acid  before  putrescence  once  more  made 
it  alkaline.  Division  of  a  single  nerve  had  the  same  result,, 
and  it  was  possible  to  cause  either  alkaline  or  acid  reaction  of 
the  various  muscles  of  one  extremity  by  respectively  leaving. 
the  nerve  entire  or  by  dividing  it.  Paltauf  also  approached  the' 
solution  of  the  question  of  the  existence  of  a  cataleptic  rigor 
mortis.  He  found  that  the  convulsive  muscular  contractions 
of  an  animal  poisoned  by  camphor  and  suddenly  killed  by 
strangling  led  to  immediate  rigor  mortis,  and  he  therefore 
believes  in  a  cataleptic  rigor  mortis. —  VVeiner  Med'chiische 
Presse. 

Some  time  previous  to  this  paper,  Prof.  Paltauf  an- 
nounced he  had  observed  "  the  greater  the  hypersesthesia 
of  the  sympathetic,  the.  greater  the  rigor  mortis;  but  if  the 
sympathetic  had  only  attained  a  condition  of  paralysis,  the 
rigor  mortis  was  very  greatly  delayed." — .S. 

*  Bodies  of  those  who  died  from  cholera,  on  resurrec- 
tion after  burial  were  sometimes  found  turned  and  twisted 
in  their  coffins;  and  this  accrues  often  to  those  that  have  suC' 

8   KKK 


—  114  — 

to  poisoned  nerve  centres,  being  phenomena  especially 
apt  to  follow  upon  specific  toxic  fatality.  And  long 
since  T.  Lauder  Brunton  recognized  the  symptoms  of 
cholera  were  precisely  paralleled  by  those  of  mus- 
carine poisoning.  Muscarine,  though  an  alkaloidal 
product  of  Agaricus  inuscarius  (fly  agaric),  is  also  a 
ptomaine,  and  consequently  of  animal  as  well  as 
vegetable  origin,  and  one  of  the  most  powerful  nerve- 
poisons  known.  Its  specific  action  is  upon  the  sym- 
pathetic, inducing  either  paralysis  or  hypersesthesia 
according  to  the  degree  of  toxicity;  it  induces,  as  just 
remarked,  all  the  phenomena  of  cholera,  even  to  stop- 
page of  the  heart  in  diastole,  and  reflex  derangement 
of  kidneys  with  suppression  of  urine;  moreover,  its 
toxic  manifestations  are  exceedingly  dilatory  for  the 
same  reason. 

Another  point  of  moment  to  be  recalled  is  that 
the  functions  of  the  sympathetic,  which  belong  to  the 
vaso-motor  group,  are  adjuvant  to  the  cerebro-spinal 
system. 

Carpenter  appears  also  to  have  had  a  partial  in- 
sight into  the  workings  of  the  sympathetic,  for  he 
says:f     The  nerves  of  this  system — "in  which  tubu- 

cumbed  to  other  specific  poisons,  as  the  result  of  decomposi- 
tion and  stimulus  of  nerve  centres  by  the  formation  of  cada- 
veric alkaloids  that  seem  to  have  the  power  of  inducing  in 
dead  tissue  the  same  phenomena  that  result  upon  galvanic 
stimulus. — S. 

■["Principles   of    Comparative    Physiology."   London, 


—  115  — 

iar  fibres  derived  from  the  cerebro-spinal  system  are 
combined  in  various  proportions  with  those  gray  or 
organic  fibres  which  have  their  centres  in  the  proper 
sympathetic  ganglia, —  possess  a  certain  degree  of 
power  of  exciting  muscular  contraction  in  the  various 
parts  to  which  they  are  distributed.  Thus  by  irritat-' 
ing  them,  contraction  may  be  excited  in  any  part  of 
the  alimentary  canal  from  the  pharynx  to  the  rectum, 
according  to  the  trunks  that  are  irritated;  in  the 
heart  after  the  ordinary  movements  have  ceased;  in 
the  aorta,  vena  cava,  and  thoracic  duct;  in  the  ductus 
choledochus,  uterus.  Fallopian  tubes,  vas  deferens, 
and  vesiculse  seminales;  and  the  very  same  contrac- 
tions may  be  excited  by  irritating  the  roots  of  the 
spinal  nerves  from  which  the  sympathetic  trunks 
receive  their  white  fibres;  and  there  is  strong  reason 
to  believe  that  the  motor  power  of  the  latter  is  entirely 
dependent  upon  the  cerebro-spinal  system.  That 
even  the  sensory  endowments  the  sympathetic  trunks 
possess,  are  probably  to  be  referred  to  the  same  con- 
nection. The  parts  exclusively  supplied  by  the  sym- 
pathetic trunks  do  not  appear  to  be  in  the  least  degree 
sensible;  and  no  sign  of  pain  is  given  when  the  sym- 
pathetic trunks  themselves  are  irritated.  But  under 
certain  diseased  conditions  of  these  organs,  violent 
pains,  are  felt  in  them;  and  these  pains  can  only  be 
produced  through  the  medium  of  fibres  communicating 
with  the  sensorium  through  the  spinal  nerves.  .  .  . 
There  is  much  reason  to  believe,  however,  that  it  (the 


—   ii6  — 

sympathetic  system)  constitutes  the  channel  througb 
which  the  passions  and  emotions  of  the  mind  affect 
the  organic  functions;  and  this  especially  through  the 
power  of  regulating  the  calibre  of  arteries.  We  have 
examples  of  the  influence  of  these  states  upon  the 
circulation  in  the  palpitation  of  the  heart  which  is 
produced  by  an  agitated  state  of  feeling;  in  the  syn- 
cope or  suspension  of  the  heart's  action  which  some- 
times comes  from  sudden  shock;  in  the  act  of  blush- 
ing or  turning  pale,  which  consists  in  the  dilatation  or 
contraction  of  the  small  arteries  (arterioles);  in  the 
sudden  increase  of  the  salivary,  lachrymal,  mammary, 
gastric  and  intestinal  secretions  under  the  influence 
of  particular  states  of  the  mind,  which  increase  is 
probably  due  to  the  temporary  dilatation  of  the 
arteries  that  supply  these  organs.*  It  is  probable  that 
the  sympathetic  system  not  only  brings  the  organic 
functions  into  relation  with  the  animal,  but  also  that  it 
tends  to  harmonize  the  former  with  the  latter,  so  as 
to  bring  the  various  acts  of  secretion,  nutrition,  etc, 
into  mutual  conformity.  The  distinctive  functions  of 
the  gray  or  organic  fibres,  and  of  their  ganglionic 
centres,  constituting  the  proper  visceral  system  .  . 
not  improbably  have  some  direct  influence  upon  the 
chemical  processes  which  are  involved  in  such  changes, 
and  may  thus  affect  the  quantity  of  such  secretions; 
whilst  the  office  of  the  tubular  fibres  may  be  rather  to- 

*Also  in  the  enuresis    and    diarrhcea    that    supervenes 
upon   fright. — S. 


—  117  — 

regulate  the  diameter  of  the  blood-vessels  supplying 
the  organ,  and  thus  to  determine  the  quality  of  their 
products." 

At  the  risk  of  prolixity,  since  the  point  to  be 
made  is  of  the  utmost  importance,  I  may  repeat  it  is 
essential  to  the  better  understanding  of  the  pathology 
of  cholera  to  note  that  the  phenomena  peculiar  to  the 
malady,  and  the  symptoms  and  manifestations  relied 
upon  for  both  ante-mortem  and  post-mortem  diagno- 
sis, are  conclusive  evidences  of  its  neurotic  origin, 
and  of  profound  toxicity  by  some  agent  closely  allied 
to  certam  alkaloids  and  acting  upon  the  central  nerv- 
ous system,  fatality  being  hastened'by  predisposing 
■causes  that  induce  depression  of  such  nerve  centres.* 


*  Toxic  alkaloids  as  the  cause  of  many  cases  of  acci- 
dental poisoning  have  come  into  prominence  of  late  years,  and 
every  summer  instances  of  ptomaine  poisoning  are  reported. 
An  interesting  article  on  this  subject  appears  in  the  "Boston 
Medical  and  Surgical  Journal"  of  August  4th,  1892.  Much 
remains  to  be  discovered  relative  to  the  kinds  of  ptomaines 
that  may  develop  in  both  animal  and  vegetable  substances 
out  of  the  body,  as  well  as  of  the  toxines  that  may  form  in 
food  after  its  ingestion.  Doubtless  the  possibilities  of 
ptomaine  formation  are  very  great,  and  under  unusual  con- 
ditions of  insalubrity — hot,  damp  weather,  sewage  emana- 
tions, etc., — the  work  of  decomposition  may  goon  with  extra- 
ordinary rapidity,  and,  under  such  influence,  tox-albumens  of 
great  power  may  form  in  food  that  to  the  eye  and  taste 
is  still  wholesome.  There  is  accumulative  evidence  to 
show  that  this  is  so.  ....  Cases 


—  ii8  — 

— That  we  do  not  know  the  poison  specifically,  is  of 
little  matter;  neither  do  we  know  whether  this  poison 
is  developed  external  to  the  economy,  or  induced 
within  the  body  through  miasmatic,  bacillar,  telluric, 
meteorologic  or  physiologic  metabolism: 

1.  Watery  diarrhoea  and  vomiting,  both  fluids 
being  odorless  and  colorless: 

2.  Tetanic  convulsions  or  cramps,  followed  hy 
muscular  flaccidity  and  lack  of  cutaneous  sensibility 
and  elasticity: 

3.  Diminished   respiration;  spasmodic   contrac- 


of  poisoning  by  food  of  a  relatively  innocuous  character  are 
not  uncommon.  Some  portion  of  the  ingesta  becomes  an 
irritant  poison,  a  fit  of  indigestion  ensues,  and  often  the 
offending  substance  is  speedily  expelled  by  vomiting.  The 
matter  of  idiosyncrasy  need  not  detain  us  here;'  it  is  known 
that  certain  articles  of  diet,  such  as  cheese  and  shell-fish,  are 
toxic  to  some  persons.  Generally  the  state  of  the  alimentary 
canal  at  the  time  is  responsible.  The  most  common  and 
best  known  of  the  various  forms  of  indigestion  is  that  in 
which,  from  the  absence  or  the  deficiency  of  gastric  juice 
and  other  digestive  fluids,  the  alimetitary  bolus  becomes  a 
gastro-intestinal  irritant,  provoking  vomiting,  purging,  and 
a  catarrhal  condition  of  the  digestive  tract.  A  second  stage 
in  the  process  of  acute  indigestion  arises  from  the  presence 
of  abnormal  fermentations  and  decompositions  in  the 
alimentary  canal.  The  food  substances  break  up  into 
organic  acids  and  alkaloidal  products  of  a  lower  order, 
which  are  in  part  absorbed  and  produce  constitutional 
disturbances.  This  stage  borders  very  closely  on  that  of 
ptomaine  formation.    There  is  good  reason  to  regard  cholera 


—   119  — 

tion  of  circular  fibres  of  bronchi,  proximate  and  ulti- 
mate; flagging  circulation,  with  more  rapid  heart- 
beat: 

4.  Depression  of  temperature  below  normal — 
perhaps  from  five  to  twenty  and  more  degrees: 

5.  vSuppressed  urinary  secretion  without  sufficient 
pathological  manifestation — manifestly  due  to  power- 
ful reflex  causes: 


nostras  and  the  gastro-intestinal  catarrh  of  infants  as  kinds 
of  ptomaine  poisoning  due  to  multiple  causes,  of  which 
weakening  of  the  alimentary  canal  and  consequent  poverty 
of  digestive  fluids,  the  ingestion  of  food  of  an  indigestible 
character,  the  putrefaction  of  the  latter  and  the  formation  of 
toxines,  are  the  principal  factors.  That  a  considerable  num- 
ber of  persons  may  simultaneously  be  attacked  with  ill- 
ness after  a  large  meal,  owing  to  the  influence  of  causes  such 
as  have  been  above  mentioned,  cannot  be  a  matter  of  serious 
doubt.  Similar  conditions  of  faulty  hygiene  produce,  in  in- 
dividuals with  similar  organic  susceptibility,  results  essenti- 
ally the  same.  A  remarkable  case  of  this  kind  occurred  in 
America  on  July  23d  of  this  year.  Out  of  a  total  of  seventy 
persons  who  dined  together,  about  fifteen  became  more  or 
less  violently  ill  within  a  few  hours,  exhibiting  the  symp- 
toms of  cholera.  The  general  opinion,  as  advanced  by 
physicians  who  had  opportunities  of  studying  the  facts  is, 
that  the  sufferers  were  persons  who  had  eaten  rather  im- 
moderately of  indigestible  dishes;  that  the  hot  weather,  the 
bad  air,  and  the  bad  water  of  the  place,  co-operated  in  bringing 
about  the  necessary  predisposition  in  the  guests,  and  that 
therefore  the  "  Salisbury  sickness  "  was  a  local  and  limited 
epidemic  of  cholera  nostras. —  77if  /.a/we/  (London),  Sept. 
17th,  1892. 


6.  Intense  thirst — an  evidence  of  functional  dis- 
turbance and  vicarious  nourishment: 

7.  Immediate  disorganization  of  blood  cor- 
puscles, similar  in  character  but  slower  in  degree  to 
that  supervening  upon  serpent  poisoning: 

8.  After  death  an  abnormal  persistent  increase 
of  temperature,  reaching  103°  Farh.  perhaps: 

9.  Speedy  post-mortem  desquamation  of  epithe- 
lium: 

10.  Post-mortem  spasmodic  muscular  contrac- 
tions such  as  follow  upon  galvanic  stimulus: 

11.  Speedy  rigor  mortis  persisting  for  an  abnor- 
mally long  period,  and  in  proportion  to  the  hyperses- 
thesia  of  the  sympathetic: 

12.  The  most  virulent  symptoms  may  usually  be 
mitigated  by  antagonizing  the  sympathetic: 

13.  One  attack  of  cholera  seems  to  protect  the 
individual  against  a  second,  in  greater  or  less  degree, 
since  recurrences  of  the  malady  are  not  frequent: 

14.  Everything  that  induces  shock  (a  purely 
nervous  condition),  or  reduces  muscle  and  nerve 
vitality — the  two  being  in  a  measure  physiologically 
synonymous  and  inter-dependent — increases  predis- 
position: 

15.  Other  epidemics,  as  influenza,  that  have  a 
depressing  effect  upon  the  nervous  system,  promote 
cholera.— All  other  diseases  during  cholera  epidemics 
become  more  aggravated  and  more  fatal  :* 

"'See  observations  on  pages  10,  il  and  127. 


i6.  Severe  attacks  of  cholera  are  especially  apt 
to  follow  wine  suppers  and  debauches  of  all  kinds — 
from  depressed  or  deficient  nerve  tone: 

17.  Fear  is  often  a  prime  factor  in  promoting 
the  spread  of  the  malady. — Though  Lebert  thinks 
this  has  obtained  undue  evidence,  because  "the 
greater  the  fear,  the  more  minutely  are  all  prelimin- 
ary measures  carried  out."  Manifestly  Lebert's  pro- 
position is  more  true  in  abstract  than  in  reality. 


CHAPTER  IX. 

PROPHYLAXIS. 

The  cause  of  cholera  has  been  shown,  then,  to  be 
some  morbid  agent  exercising  a  toxic  effect  through 
the  central  nervous  system.  The  precise  nature  of  the 
agent  is  unknown,  but  its  effects  are  only  too  appar- 
ent; and  experience  has  taught  that  it  attacks  the 
poor  in  a  much  larger  proportion  than  the  rich,  the 
unclean  rather  than  those  practicing  sanitation  and 
the  laws  of  hygiene. 

It  is  also  well  known  that  in  proportion  to  the 
prevention  of  distribution  of  water  fouled  with  sewage, 
and  to  the  removal  of  destitution,  filth,  foul  air,  and 
other  great  factors  of  disease,  so,  generally,  is  de- 
stroyed the  agency  through  which  the  cholera  poison 
operates. — Thos.  Hawkes  Tanner,  especially  remarks 
the  lesson  taught  by  the  epidemics  of  1853-54  and 
1865-66  in  England,  viz.,  that  even  poverty-stricken 
denizens  of  an  unhealthy  neighborhood,  supplied  with 
pure  water,  are  more  certam  to  escape  than  the 
wealthy  residents  of  fashionable  parks  and  squares 
when  the  latter  consume  bad  water.  Still,  that  over- 
crowding is  an  important  factor  in  disseminating  the 
malady — probably  through  re-consumption  of  exhaled 
gases  of  respiration,  tending  to  poisoning  of  the  cir- 
culation and  central  nervous  system  with  carbonic 
oxide — is  not  to  be  denied.     Within  the  walls  of  an 


—    123   — 

establishment  for  pauper  orphans  at  Tooting,  Eng- 
land, in  1853-54  there  were  assembled  1,395  children, 
little  more  than  one  hundred  cubic  feet  of  breathing 
space  being  available  for  each  child,  against  a  require- 
ment of  1,500  (and  500  is  the  very  smallest  com- 
patible with  health).  Here,  in  a  single  night,  the 
epidemic  seized  sixty-four  of  the  inmates,  300  bemg 
laid  low  within  a  week,  during  which  time  180  died. 
Again,  in  the  workhouse  at  Taunton,  with  276  occu- 
pants, and  with  breathing  space  in  many  of  the  rooms 
not  exceeding  sixty-eight  cubic  feet  for  each  person, 
cholera  swept  away  nearly  twenty-four  per  cent,  in  the 
brief  period  of  six  days;  while  in  the  gaol  of  the 
same  town,  where  each  prisoner  had  a  breathing 
space  of  nearly  900  cubic  feet  (and  in  some  instances 
more),  not  a  single  case  of  cholera  or  diarrhoea  oc- 
curred ! 

When  an  epidemic  is  prevalent,  there  are  also 
certam  conditions  other  than  filthy  surroundings,  bad 
water,  and  foul  air,  that  render  individuals  liable  to 
the  disease,  such  as  unwholesome,  indigestible  food — 
stale  meat  and  fish,  game  that  is  "high,"  butcher- 
made  sausages  (since  these  latter  are  largely  worked 
up  from  scraps  and  unsold  remnants  at  the  spoiling 
turn),  withered  vegetables,  over-  or  under-ripe  fruit, 
etc.  Other  predisposing  causes  are  vitiated  damp  air; 
exposure  to  all  forms  of  miasm;  intemperance;  insuffi- 
cient protection  from  cold  and  inclement  weather; 
excessive  fatigue;    long  abstinence  from  food;    diar- 


124    — 

rhoea;  in  fact  all  irregular  habits,  including  loss  of 
sleep,  excessive  venery,  et  al. 

Hence  the  old  maxim  of  an  ounce  of  prevention 
vs.  a  pound  of  cure,  in  this  malady  receives  apt  illus- 
tration. To  secure  immunity  it  is  essential  to  form 
regular  habits  of  life — to  live  by  rule,  in  a  measure, 
for  sudden  radical  changes,  even  if  for  the  better  in 
a  general  way,  are  sometimes  prone  to  work  an  effect 
quite  the  reverse  of  that  sought.  It  is  important  the 
residence  should  be  in  a  clean,  dry,  airy  locality,  in  a 
house  that  has  no  defects  in  sanitation,  whether  from 
plumbing,  from  decaying  wood,  or  from  water  beneath 
the  floors;  to  avoid  the  use  of  purgatives,  especially 
of  an  acrid  or  drastic  nature — the  patent  liver-pills, 
"pleasant"  pellets  and  other  nostrums,  are  extremely 
pernicious,  the  larger  containing  aloes,  the  smaller 
aloin,  croton  oil,  or  elaterium;  to  check  any  manifest 
laxity  of  the  prima  vice  by  rest  in  the  recumbent  pos- 
ture and  employment  of  plain  farinaceous  foods; 
to  use  for  drinking  purposes  only  water  that  has  been 
boiled,  and  when  cold  filtered  through  a  mixture  of 
sand  and  charcoal — I  may  state  a  personal  preference 
for  rain  water  filtered  through  the  Kedzie  filter,  which 
I  employed  for  many  years. 

If  there  is  matter  within  the  intestines  tending 
to  irritation,  this  should  be  gotten  rid  of  by  means 
of  a  simple  aperient — Hunyadi  Janos  water,  the  effer- 
vescing draughts,  castor  oil,  or  the  like;  or  if  there 
are    loose,    watery    evacuations,    modification  of   the 


—  125  — 
secretions  may  be  obtained  by  small  and  repeated' 
doses  of  leptandrin,  bismuth  or  cerium  oxalate, 
ipecac,  and  camphor  monobromide,  combined;  or 
by  chloroform  water  or  spirit;  by  coto;  by  chlor- 
anodyne;  these  may  be  employed  either  with  or 
without  aromatics.  The  tendency  to  intestinal  flux, 
even  if  not  choleraic,  is  necessarily  a  source  of 
danger  in  that  it  must  needs  be  more  or  less  de- 
bilitating, thus  inducing  a  condition  that  pre- 
disposes the  individual  to  receive  the  cholera 
virus.  It  is  obvious  that  conservation  of  the  vital 
powers  is  of  the  utmost  importance;  but  that  an 
ordinary  diarrhoea,  the  result  of  indiscretion  in  eating, 
of  "  taking  cold,"  etc.,  can,/<?r  se,  produce  the  specific 
germ  of  cholera,  as  some  seem  to  imagine,  is  ridicu- 
lous to  the  extreme  of  absurdity. 

But  right  here  let  it  again  be  impressed  that  dur- 
ing a  cholera  epidemic  the  precise  character  of  any 
diarrhoea  must  necessarily  be  difficult  of  determina- 
tion ;  it  may  be  truly  choleraic,  yet  never  manifest  its 
real  nature,  and  thus  become  a  source  of  infection. 
For  this  reason,  on  such  occasions  all  stools  should  be 
carefully  gathered  and  cremated— no  other  measure 
is  positively  safe, — not  emptied  into  the  closet  or 
privy;  and  these  latter  receptacles  should  be  carefully 
disinfected.  Again,  no  traveler  or  stranger  should 
be  permitted  to  use  such  closets— not  even  a  neigh- 
bor; and  no  person  should  ever  venture  to  enter  a 
strange  closet,  privy,  or  latrine,  since,  as  has  already 


126    

been  shown,  the  emanations  therefrom  may  communi- 
cate the  infection.  No  device  of  sanitary  expert,  or 
care  of  plumber,  has  yet  sufficed  to  render  a  closet 
perfectly  safe.  The  practice  of  wearing  a  broad, 
thick  web  of  flannel  as  a  belt,  snugly  embracing  the 
abdomen,  as  a  prophylactic  against  intestinal  disturb- 
ances, far  from  being  reprobated  should  be  encour- 
aged, especially  among  those  of  advanced  life  or 
sedentary  habits. 

Clothing  soiled  by  diarrhceaic  evacuations,  whether 
the  linen  of  the  person  or  of  the  bed,  should  at  least 
be  subjected  to  the  prolonged  action  of  intensely  hot 
water — be  boiled,  in  fact, — and  also  of  strong  antisep- 
tics, as  measures  of  safety;*  and  if  there  is  any  suspi- 
cion of  choleraic  tendency,  it  is  greatly  to  be  preferred 
they  too  go  to  the  fire.  With  all  our  boasted  knowl- 
edge of  antiseptics  and  antisepsis,  we  are  as  greatly 
in  the  dark  as  to  what  is  available  in  destroying  the 
poison  of  cholera,  the  element  of  fire  excepted,  as  we 
are  regarding  the  precise  nature  of  the  virus. 

Finally,  it  may  not  be  generally  known  that  there 
is  no  disease  in  the  whole  nosological  record  that  is 
more  aided  in  the  onset,  and  the  fatal  tendencies  of 


^I  have  already  shown  that  Zehnder  ascribed  the  origin 
of  two  cholera  centres  in  Zurich  in  1867,  to  an  accumulation 
of  bedding,  mattresses,  pillows,  etc.,  which  had  been  used 
on  the  beds  of  cholera  patients,  and  which  before  disinfec- 
tion were  piled  up  in  the  neighborhood  of  the  houses  af- 
fected!— S. 


127    — 

which  are  more  vigorously  promoted  and  hastened  by 
mental  depression  and  fear,  than  cholera — less  fear  of 
cholera  itself,  however,  than  developed  through  other 
sources.    The  fact  is,  this  malady  in  the  main  claims 
far  fewer  victims  in  proportion  to  the  general  popula- 
lation  of  any  one  country  than  many  others  that  are 
regarded  with  comparative  complaisance  and  often 
receive  scarce  passing  attention    save  from  medical 
men   and   those  whose   homes   are  directly  invaded. 
Yearly  whole  districts  are  ravaged  by  typhoid  fever, 
diphtheria,  scarlatina,  etc.,  to  a  greater  degree  than 
cholera  is  apt  to  do;  further,  I  believe  there  are  no 
valid  reasons,  other  than  the  rapidity  of  the  attack 
and  the  brief  period  that  may  elapse  between  incep- 
tion and  fatality,  for  regarding  this  disease,  in  fairly 
sanitary    localities,    as    ultimately   more    dangerous, 
taking  into  consideration    all    results,  than  epidemic 
influenza.     Again,  it  is  notable  that  on  every  occasion 
when    it  assumes   its  most  malignant  and    epidemic 
form,    and   spreads   beyond   the    boundaries   of   the 
regions  where    it  is  endemic,  there  have    been    me- 
teorologic  or  telluric   conditions,   or  both,  favorable 
to   its  dissemination;    that  generally  throughout   the 
temperate  regions   of  the   globe,  as  well    as   in   the 
tropics,  a  marked  tendency   to    enteric  disease  pre- 
vails*.    In  the  present  year  (1892),  as  in    1891,  this 

*  As  early  as  the  beginning  of  1827  cholera  appeared 
with  renewed  intensity  at  Calcutta,  and  here  it  is  mentioned 
for  the  first  time   that  many   animals  also  showed  the  influ- 


—    128    — 

latter  fact  has  been  most  manifest,  and  never  for 
twenty-five  years  has  the  diarrhoeaic  mortality  of^ 
London,  Paris,  Berlin,  and  other  European  cities 
reached  greater  height  than  during  the  past  summer. 
The  present  epidemic,  as  has  been  shown,  readily 
found  its  way  into  Russia,  where,  by  reason  of  the 


ence  of  the  disease  (p.  365).  ...  It  was  observed  in 
North  Germany  at  that  time  (1831)  that  chickens  and  pigeons, 
and  in  many  instances  fishes,  perished  in  great  numbers 
(p.  359). — Ziemssen's  "Cyclopaedia  of  Practical  Medicine," 
vol.  i. — See  Appendix  A. 

Even  in  India  the  development  of  cholera  demands  a 
medium  degree  of  humidity  of  the  soil  and  air.  Great  and 
protracted  dryness,  as  well  as  excessive  long-continued 
moisture  of  the  soil,  are  alike  unfavorable;  therefore  it  is 
that  in  the  hot  regions  of  the  East  Indies,  where  dryness 
predominates  and  rainfalls  are  scanty,  the  cholera  breaks 
out,  as  a  rule,  in  the  rainy  season;  while  in  the  hot  regions 
of  lower  Bengal,  wher^  wet  weather  predominates  and  rain- 
falls are  abundant,  the  malady  prevails  in  spring  seasons 
which  lack  their  usual  rain.  Great  weight  is  attached  to  the 
monsoon  season  by  Indian  physicians,  who  for  the  most  part 
in  past  years  have  been  upholders  of  the  miasmatic  theory. 
Von  Pettenkofer  undoubtedly  states  the  truth  when  he  ex- 
plains the  influence  of  the  monsoon  by  the  saturation  of  the 
soil.  Again,  in  Paris  in  1849,  after  a  wet  spring,  cholera 
reached  an  unusual  degree  of  fatality  in  the  first  eight  days, 
of  June,  which  were  very  warm;  on  the  ninth,  however, 
occurred  a  violent  storm,  when  the  number  of  new  attacks 
diminished  one-third  as  compared  with  the  days  of  the  pre- 
ceeding  week.  The  same  was  true  in  the  same  year  at 
Vienna,  in  Austria,  and  Christiania,  in  Denmark.— S. 


—  129  — 
famine  and  the  consequent  train  of  circumstances 
which  make  an  entire  population  susceptible  to  ad- 
ditional scourge,  it  obtained  firm  foothold,  and  thence, 
in  spite  of  sanitary  barriers,  reached  the  more  civilized 
portions  of  Europe;  the  same  circumstances,  precisely, 
existed  in  Southern  Ireland  prior  to  and  during  the 
epidemic  of  1834,  in  which  locality  the  malady  was 
exceptionally  fatal  until  the  famine  was  in  great 
measure  relieved,  and  wholesome  food  became  the  rule 
rather  than  the  exception — thanks  to  the  bounties  of 
the  world. 

This  with  reference  to  the  epidemic  form  of  chol- 
era; for  it  must  be  remembered  that  sporadic  cholera 
like  the  poor,  is  "always  with  us"  to  greater  or  less 
extent,  and  constantly  exists  in  the  Levant,  in  Southern 
Europe  along  the  Mediterranean,  and  occasionally  ap- 
pears as  an  endemic  even  on  the  borders  of  the  Ger- 
man Ocean,  and  in  the  far  interiors  of  Canada  and  the 
United  States:  The  fact  these  sporadic  cases  are 
generally  classed  as  aggravated  cholera  morbus,  chol- 
era nostras,  English  cholera,  cholera  infantum,  etc., 
matters  little,  since  they  are  pathologically  one  and 
the  same,  differing  only  in  degree — an  opinion  that 
is  upheld  by  the  very  highest  authorities  in  India  and 
Europe.*     And   I    here   insist,  taking   every   feature 

*See  "  Pathological  Researches"  of  T.  R.  Lewis;  Lon- 
•don,  188S.  "  Nature  and  Treatment  of  Sporadic  and  Epi- 
demic Cholera,"  by  Alex.  Harkin,  London,  1885.  "On  the  Ori- 
gin, Habits,  and  Diffusion  of  Cholera,"  by  Sir  J.  Fayrer,  K, 
C.  S.  L,    M.  D.,  F.  R.  S. 

9  KKK. 


—  I30  — 

into  consideration,  and  giving  all  negative  evidence 
due  weight,  that  cholera  is  cholera  wherever  it  occurs, 
and  its  epidemic  prevalence  and  intensity  are  phases 
or  accidents  in  its  history.  Surgeon-Majors  D.  D. 
Cunningham,  and  J.  M.  Cunningham,  the  latter  the 
Health  Commissioner  of  India,  and  many  others  who 
are  very  properly  considered  as  expert  authorities  on 
Asiatic  cholera,  believe  that  cholera  nostras  is  the 
same  precise  malady,  "  exhibited  under  conditions 
unfavorable  for  its  perfect  expression — that  at  times 
the  conditions  may  and  do  become  favorable,  and 
then  an  epidemic  results."  The  disease  occurring 
in  the  deltas  of  the  Ganges  and  Trawadi,  in  Moscow, 
Hamburg,  London,  New  York  or  Winnipeg,  is  practi- 
cally the  same;  and  within  a  quarter  of  a  century 
I  have  seen  numerous  cases  in  the  Great  Lake  region 
of  North  America  as  serious  as  any  that  ever  bore 
the  name  Asiatic,  two  that  would  have  been  pro- 
nounced asphyctic  had  the  malady  only  been  raging^ 
as  an  epidemic  ! 

[Since  the  above  was  written,  it  has  been  my  lot 
to  see  three  other  cases  of  cholera  nostras  (morbus)  in 
Detroit,  either  of  which  was  so  virulent  there  would 
have  been  not  the  least  hesitancy  on  the  part  of  any- 
one viewing  in  pronouncing  true  Asiatic  cholera,  had 
there  been  the  slightest  chance  of  infectious  origin. 
I  may  further  add,  the  bacillus  of  Koch  was  specifically 
identified  in  the  dejections  of  all  three;  also,  that  all 
were  speedily  relieved  by  inhibition  of  the  sympa- 
thetic] 


—  13'  — 
Owing,  presumably,  to  the  utter  failure  of  rem- 
edies, external  or  internal,  to  check  the  march  of  this 
dire  disorder,  the  efforts  of  medical  men  for  the  most 
part — almost  exclusively,  I  should  say — have  been 
directed  to  measures  of  prevention;  and  it  is  perhaps 
for  this  as  well  as  for  other  reasons,  that  the  therapeu- 
sis  of  cholera  has  not  kept  pace  with  that  of  other 
diseases.  Sanitary  measures  have  almost  wholly 
superseded  sanatory  considerations,  and  to  such  an 
extent  that  in  most  dissertations  of  the  leading  advo- 
cates of  State  Medicine,  the  former  are  gravely 
heralded  as  panaceas  for  all  epidemic  disorders,  and 
sure,  in  course  of  time,  to  eliminate  from  the  nosologi- 
cal record  the  whole  train  of  such  accidents.  Says 
Dr.  Alex.  Harkin:* 

"These  enthusiasts  seem  to  have  adopted  for 
their  motto,  and  emblazoned  on  their  'banner 
with  the  strange  device,'  Sanitas  Sanitattim,  et  o?nnia 
Sanitasj  and  yet  I  fear  the  saying  of  the  Wise  Man, 
Va?iitas  Vanitatuni,  et  omnia  Vanitas,  is  not  alto- 
gether obsolete  in  their  regard,  but  fairly  applicable 
to  many  of  their  most  confident  vaticinations.  I 
am  not  one  unfairly  to  decry  the  value  of  sanitation 
or  scientific  hygiene — I  should  rather  prefer  that  san- 
itary and  therapeutic  measures  should  go  hand-in- 
hand;  but  in  the  recent  experience  of  a  fatal  form  of 
typhoid  fever,  which  numbered  many  victims  in  some 


*  Dublin  Journal  of  Medical  Sciences    March,  1890. 


—  132  — 
of  the  finest  cities  of  America,  France,  and  Ireland, 
and  in  the  actual  presence  of  epidemic  influenza  which 
has  prostrated  thousands  in  the  British  Isles  and  on 
the  continents  of  Europe  and  America,  the  impotence 
of  sanitary  arrangements  to  alone  repel  an  attack 
of  infectious  disorder  must  be  hopelessly  apparent."* 
Looking  at  the  history  of  cholera  in  Malta  ante- 
cedent to  1887,  we  find  after  the  epidemic  of  1865, 
considered  the  most  fatal  up  to  that  date  on  record, 
every  measure  that  sanitary  science,  or  engineering 
skill  could  effect  was  carried  out;  yet,  notwithstand- 
ing, the  cholera  unheeding  swept  down  upon  the 
Island  in  1887  in  a  more  malignant  form  than  ever,  for 
out  of  626  cases  only  164  recovered — a  death  rate  of 
73.5  per  cent.  In  1865,  after  which  Dr.  Sutherland 
and  the  eminent  engineer  Osbert  Chadwick  visited 
the  Island,  the  mortality  stood  at  60  per  cent.;  while 
in  1867,  an  intermediate  visitation,  there  was  a  mor- 
tality of  only  64  per  cent.,  and  this  before  the  sani- 
tary improvements  were  complete.  In  the  presence 
of  such  adverse  statistics  it  is  difficult  to  agree  wholly 
with  sanitary  scientists. 


"'This  conviction  appears  to  be  entertained  by  some  of 
the  most  enlightened  organs  of  public  opinion,  as  I  find  in 
an  able  article  on  Influenza  in  the  Standard  (London)  this 
sentence:  "And  those  who  hoped  that  in  the  case  of  this,  as 
of  more  serious  scourges,  the  comparative  excellence  of 
sanitation  would  secure  an  absolute  immunity,  have  to  con- 
fess they  have  carried  their  faith  in  drainage  a  little  too  far!" 


Antiseptics  and  Disinfectants 

FOR  THE  PREVENTION  OF  CHOLERA. 


We  desire  to  call  attention  to  the  following  antiseptic  and  disinfectant 
preparations: 

Ethereal  Antiseptic  Soap  (Johnston's)  is  a  hydro-alcoholic  solution 
of  Castile  soap  which  was  devised  by  an  experienced  nurse  in  the  surgi- 
cal clinic  of  the  Jefferson  Medical  College.  It  may  be  made  weak  or 
strong  in  antiseptic  value  by  dissolving  mercuric  chloride  in  it  in  propor- 
tions indicated  in  the  case  in  hand.  Since  its  introduction  its  use  has 
been  extended  to  the  treatment  of  parasitic  affections  with  much  success. 

Antiseptic  Liquid  arrests  decomposition  and  destroys  noxious 
gases  that  emanate  from  organic  matter  in  sewers  and  elsewhere,  and 
may  be  used  in  cellars,  barns,  outhouses,  and  the  sick-room.  (Send  for 
Note  on  the  Disinfectant  of  the  Future,  by  Prof.  Alfred  L.  Loomis.) 

Antiseptic  Tablets  are  convenient  for  the  extemporaneous  prepa- 
ration of  antiseptic  solutions  of  definite  strength  for  disinfectant  purposes 
and  for  antiseptic  sprays. 

Eucalyptus  and  Thymol  Antiseptic  is  adapted  for  use  as  an  anti- 
septic internally,  externally,  hypodermatically,  as  a  douche,  a  spray,  by 
atomization,  and  as  a  deodorant.  Its  application  in  surgery  is  unlimited. 
It  combines  the  antiseptic  virtues  of  benzoic  acid,  boric  acid,  oil  pepper- 
mint, oil  eucalyptus,  oil  wintergreeti,  oil  thyme  and  thymol. 

Disinfectant  Po'wder  possesses  in  a  high  degree  disinfectant,  ab- 
.sorbent,  and  antiseptic  properties.  It  is  admirably  adapted  for  the  dis- 
infection of  excreta  in  cholera,  yellow  fever,  and  typhoid  fever,  and  in 
all  diseases  in  which  such  an  agent  is  indicated  for  the  purpose  specified, 

Labarraque's  Solution  we  supply  for  the  use  of  those  who  desire 
to  employ  it  for  its  local  or  internal  antiseptic  action.  It  may  be  diluted 
to  suit  the  indications. 

Sulphur  Candles  thoroughly  employed  are  effectual  in  the  fumiga- 
tion and  disinfecting  of  rooms  after  infectious  diseases. 

fVe  shall  he  pleased  to  forward,  on  request,  any  information  desired  con- 
cerning these  products. 


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Inhalers.  Inhalations  and  Inhalants. 

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The  Use  of  Electricity  in  the  Removal  of 
Superfluous  Hair  and  the  Treatment  of 
Various  Facial  Blemishes. 
By  Geo.  Henry  Fox,  M.  D. 
New  IVIedications,  Vol.  I. 

By  Dujardin-Beaumetz,  M.  D. 

New  MedicafionSi  Vol.  II. 

By  Dujardin-Beaumetz,  M.  D. 
The  Modern  Treatment  of  Ear  Diseases. 

By  Samuel  Sexton,  M.  D. 
The  Modern  Treatment  of  Eczema. 

By  Henry  G.  Pilfard.  M.  D. 


Antiseptic  Midwifery. 

By  Henry  J.  Garrigues,  M.  D. 
On  the  Determination  of  the  Neoessityfor 
Wearing  Glasses. 

By  D.  B.  St.  John  Roosa,  M.  D. 
The  Physiological, Pathological  and  Ther- 
apeutic Effects  of  Compressed  Air. 

By  Andrew  H.' Smith,  M.  D. 
GranularLidsandContagiousOphthalmia. 

By  W.  F.  Mittendorf ,  M.D. 
Practical  Bacteriology. 

By  Thomas  E.  Satterthwaite,  M.D. 
Pregnancy,    Parturition,   the    Puerperal 
State,  and  their  Complications. 

By  Paul  F.  Mund^,  M.  D. 


SERIES   II. 


The  Diagnosis  and  Treatment  of  Haem- 
orrhoids. 
By  Chas.  B.  Kelsey,  M.  D. 

Diseasesof  the  Heart,  Vol.  I. 

By  Dujardin-Beaumetz,  M.  D. 

Diseases  of  the  Heart,  Vol.  II. 

By  Dujardin-Beaumetz,  M.  D. 
The  Modern  Treatment  of  Diarrhoea  and 
Dysentery. 

By  A.   B.    Palmer,  M.   D. 
Intestinal  Diseases  of  Children,  Vol.  I. 

By  A.  Jacobi,  M.  D. 
Intestmal  Diseases  of  Chilaren,  Vol.  II. 

By  A.  Jacobi.  M.  D. 


The  Modern  Treatment  of  Headaches. 

By  Allan  McLane  Hamilton,  M.  D. 
The  Modern  Treatment  of  Pleurisy  and 
Pneumonia. 

By  G.  M.  Garland,  M.  D. 

Diseases  of  the  Male  Urethra. 

By  Fessenden  N.  Otis,  M.  D. 
The  Disorders  of  Menstruation. 

By  Edward  W.  Jenks,  M.  li. 

The  Infectious  Diseases,  Vol.  I. 

By  Karl  Liebermeister. 
The  Infectious  Diseases,  Vol.  II. 

By  Karl  Liebermeister. 


SERIES   III. 


Abdominal  Surgery. 

By  Hal  C.  Wyman,  M.  D. 
Diseases  of  the  Liver- 

By  Dujardin-Beaumetz,  M.  D. 
Hysteria  and  Epilepsy. 

By  J.  Leonard  Corning^,  M.  D. 

Diseases  of  the  Kidney. 

By- Dujardin-Beaumetz,  M.  D. 

The  Theory  and  Practice  of  the  Ophthal- 
moscope. 

By  J.  Herbert  Claiborne,  Jr.,  M.  D. 

Modern  Treatment  of  Bright's  Disease. 
By  Alfred  L.  Loomis,  M.  D. 


Clinical  Lectures  on  Certain  Diseases  of 
the  Nervous  System. 

By  Prof.  J.  M.  Charcot,  M.  D. 

The  Radical  Cure  of  Hernia. 

By  Henry  O.  Marcy,  A.  M.,  M.  D., 
LL.  D. 
Spinal  Irritation. 

By  William  A.  Hammond,  M.  D. 
Dyspepsia. 

By  Frank  Woodbury,  M.  D. 
The  Treatment  of  the  Morphia  Habit. 

By  Erlenmeyer. 
The  Etiology,  Diagnosis   and  Therapy  of 
Tuberculosis. 

By  Prof.  H.  von  Ziemssen. 


SERIES   Ii:. 


Nervous  Syphilis. 

By  H.  C.  Wood,  M.  D. 
Education  and  Culture  as  correlated  to 
the  Health  and  Diseases  of  Women. 

By  A.  J.  C.  Skene,  M.  D. 
Diabetes. 

By  A.  H.  Smith,  M.  D. 
A  Treatise  on  Fractures. 

By  Armand  Despres,  M.  D. 
Some  Major  and  Minor  Fallacies  concern- 
ing Syphilis. 

By  E.  L.  Keyes,  M.  D. 
Hypodermic  Medication. 

By  BourneviTle  and  Bricon. 


Practical    Points  in  the  Management  of 
Diseases  of  Children. 

By  I.  N.  Love,  M.  D. 
Neuralgia. 

By  E.  P.  Hurd,  M.  D. 
Rheumatism  and  Gout. 

By  F.  Le  Roy  Satterlee,  M.  D. 
Electricity,  Its  Application  in  Medicine. 

By  Wellington  Adams,  M.D.    [VoLL] 
Electricity,  Its  Application  in  Medicine. 

By  Wellington  Adams,  M.D.  [Vol.H.] 
Auscultation  and  Percussion. 

By  Frederick  C.  Shattuck,  M.  D. 


SERIES    V. 


Taking  Cold. 

By  F.  H.  Bosworth,  M.D. 

Practical  Notes  on  Urinary  Analysis. 
By  William  B.  Canfield,  M.  D. 

Practical  Intestinal  Surgery.    Vol.  L 

By  F.  B.  Robinson,  M.  D. 
Practical  Intestinal  Surgery.    Vol.  H. 

By  F.  B.  Robinson,  M.  D. 

Lectures  on  Tumors. 

By  John  B.  Hamilton,  M.  D.,  LL.  D. 

Pulmonary  Consumption,  a  Nervous  Dis- 
ease. 

By  Thomas  J .  Mays,  M.D. 


Artificial  Anaesthetics  and  Anaesthesia. 
By  DeForest  Willard,  M.  D.,  and  Dr. 
Lewis  H.  Adler,  Jr. 

Lessons  in  the  Diagnosis  and  Treatment 
of  Eye  Diseases. 

By  Casey  A.  Wood,  M.  D. 
The  Modern  Treatment  of  Hip  Disease. 

By  Charles  F.  Stillman,  M.  D. 
Diseases  of  the  Bladder  and  Prostate. 

By  Hal  C.  Wyman,  M.  D. 
Cancer. 

By  Daniel  Lewis,  M.  D. 
Insomnia  and  Hypnotics. 

By  Germain  See . 

[Translated  by  E.  P.  Hurd,  M.  D.l 


SERIES   VI. 


The  Uses  of  Watec  in  Modern  Medicine. 
By  Simon  Baruch,  M.  D.        Vol.  I . 

The  Uses  of  Water  in  Modern  Medicine. 
By  Simon  Baruch,  M .  D .      Vol.  II. 

The  Electro-Therapeutics  of  Gynaecol- 
ogy. Vol.  1. 
By  A.  H.  Goelet,  M.  D. 

The  Electro-Therapeutics  of   Gynaecol- 
ogy. Vol.  H- 
By  A.  H.  Goelet,  M.  D. 

Cerebral  Meningitis. 

By  Martin  W.  Barr,  M.  D. 

Contributions  of  Physicians  to    English 
and  American  Literature. 
By  Robert  C.  Kenner,  IM.  D. 


Gonorrhoea  and  Its  Treatment. 
By  G.  Frank  Lydston,  M.  D 

Acne  and  Alopecia. 

By  L.  Duncan  Bulkley,  M.  D. 

Fissure  of  the  Anus  and  Fistula  in  Ano, 
By  Dr.  Lewis  H.  Adler,  Jr. 

The   Surgical   Anatomy  and    Surgery  of 
the  Ear. 
By  Albert  H.  Tuttle,  M.  D.,  S.  B. 

The  Masseur's  Manual  of  Medical  Gym- 
nastics. 
By  Baron  Nils  Posse. 

Sexual  Weakness  and  Impotence. 
By  Edward  Martin,  M.  D. 


SERIES  VII. 


Appendicitis  and  Perityphlitis. 

By  Charles  Talamon,  M.  D. 
Cholera.    Vol.  i. 
Cholera.    Vol.  ii. 

ByG.  Archie Stockwell,  M.D.,F.Z.S. 
Electro-Therapeutics  of  Neurasthenia. 

By  W.  F.  Robinson,  M.  D. 

Diagnosis    and    Treatment  of   Surgical 
Affections  of  the  Peripheral  Nerves. 

By  F.  Jenner  Hodges,  M.  D. 
Deformities  of  the  Foot. 

By  B.  E.  McKenzie,  M.  D. 


Treatment  of  Sterility  in  the  Woman. 
By  Dr.  De  Sinety. 

Bacterial  Poisons. 

By  N.  Gamaleia.  M.  D. 

Treatise  on  Diphtheria. 

By  H.  Bourge^,  M.  D. 
Antiseptic  Therapeutics.    Vol.  i. 
Antiseptic  Therapeutics.    Vol.  ii. 

By  E.  Trouessart.  M.  D. 

Treatment  of  Typhoid  Fever. 
By  Juhet-Renby,  M.  D. 


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